What Can A Physician Do When A Patient Shows Up Carrying A Gun? In Some Places, Not Very Much

Can a physician make his office a gun-free zone?  That may seem like a question with an obvious answer but it’s not.  And the answer isn’t obvious because of a pending bill that would extend concealed-carry privileges on a reciprocal basis to all 50 states.  And the bill doesn’t carry an opt-out provision at the state level.  In other words, if I can carry a concealed weapon in my state of residence, I can basically carry it anywhere in the United States, even if the requirements for getting a concealed-carry license are different in my home state than in the state where I happen to be.

docs versus glocks           I was drawn to this issue today because of an article published by a physician in who found herself confronted in her practice by a patient carrying a gun. Actually, he was carrying two handguns, both loaded, which he took off in order to be given an EKG.  And the existence of the guns didn’t particularly concern Dr. Becher per se, because she practices in West Virginia where, as she put it, everyone including herself owns guns. But she just didn’t feel comfortable around this guy and her discomfort became intense when he made a threatening remark about a subspecialist to whom Dr. Becher had referred him the previous week.

She then learned from contacting law enforcement that she could not prevent him from coming into her practice until and unless he was told to his face that he could show up with guns, even if there was a sign on the office door stating that the office was a gun-free zone.  She could send him a letter dismissing him as a patient but this still could not prevent him from simply walking through the front door.

The national concealed-carry reciprocity bill, which now has almost enough sponsors to guarantee that it will pass a House vote, actually makes Dr. Becher’s situation a national policy if it becomes law. Because the bill says that it does not ‘supersede or restrict’ any private property owner from denying access to their property by anyone carrying a gun.  But notice that in West Virginia the state law still requires a property-owner to confront the armed citizen face-to-face in order to maintain the property as a gun-free zone.

Now believe it or not, there actually are a few deranged individuals claiming to be physicians who believe that Dr. Becher and all physicians will be safer and more secure if they allow anyone and everyone to enter their practice carrying guns.  In fact, these fools actually take the position that physicians should encourage their patients to carry guns.  I am referring, of course, to the pathetic bunch known as Doctors for Responsible Gun Ownership (DRGO) who have been parroting the NRA attacks against medicine since the AAP and other medical groups had the temerity, the unmitigated audacity to state the obvious, namely, that guns represent a health risk? How in God’s name could a quarter-ounce piece of lead that hits soft tissue faster than the speed of sound be a threat to good health? And yet on the same day that Dr. Becher raised her concerns about how to deal with the threatening patient carrying two weapons, an online medical blog that caters to a right-wing readership published a DRGO screed calling for doctors to avoid any discussion with patients about guns.

There are two problems here that need to be addressed.  First is the fact that physicians cannot act alone when it comes to protecting themselves and their patients from gun violence – they need help from law enforcement, from the public, and most of all, from reasonable and responsible politicians who draft and enact laws.  Second is the fact that the sponsors of the national CCW-reciprocity bill aren’t behaving responsibly at all.  They may believe they are making it easier for citizens to protect themselves, but what they are really doing is creating risk. Which has to stop – now.

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Is Gun Violence A Recurring Disease? A New Study Says ‘Yes.’

What are the odds that someone who is discharged from a hospital after treatment for a gunshot injury will return to the hospital with another serious injury or will be arrested for committing a serious crime?  For the first time a study attempts to answer that question based on enough data to discuss how the medical community should respond to people who seek medical help after being assaulted with a gun.  The Annals of Internal Medicine contains a study of more than 9,000 patients who were admitted to hospitals in Washington State with violent injuries in 2006-2007 and were then followed through December, 2011 or to their next subsequent hospitalization, arrest, or death, or whichever came first.  The findings about this group were then compared to 68,000 patients who were discharged during the same two-year period but had been treated for non-violent injury, along with a comparison to 180,000 patients comprising the general population.

conference program pic                Before we compare the long-term experiences of all three groups, let’s look at the composition of the violent injury group itself.  Of all patients treated between 2006 and 2007 for violent injury, roughly 7.5% were admitted for injuries involving guns, or what the researchers refer to as firearm-related hospitalizations or FRH.  But the FRH number was actually 21% of all assaults, since 65% of all serious injuries were self-inflicted (accidents and the like.)  The ratio of one out of five assaults in which a gun was used is no different from what the FBI reports across the nation as a whole.

Patients admitted in 2006-2007 for gun injuries were also typical of this population in general, with nearly 75% being less than 40 years old, and 85% being male.  Racial data was not available for this study, but interestingly, one-third of all victims of gun violence in Washington State paid their hospital bills with private insurance, whereas the Urban Institute recently calculated that less than 5% of all hospital admissions for gun-related violence were covered by private plans.

Here’s the bottom line.  A patient who was treated and discharged for a gun injury in 2006 and 2007 had a significantly higher chance of then being killed with a gun or being arrested for some kind of violent assault.  A history of criminality prior to the hospitalization increased the likelihood of post-discharge victimization or criminal behavior even further.  The point is that a medical encounter for the treatment of gun violence does not just represent a challenge to respond to the injuries caused by the specific gun-related event.  It is also a harbinger of further medical challenges to come and should be understood and responded to in the context of an ongoing and continuous medical risk.

Other studies have also shown that violent injury is a recurring disease.  Earlier this year JAMA Pediatrics published an article which showed a clear division between two youthful populations, ages 14-24, who were treated by Emergency Departments in Flint, MI.  The groups were divided between those patients whose first visit to the ER was for violent injury, the other group came to the ER for something else.  What then happened was that a significant number of the patients who first sought medical care for injury returned to seek care for the same problem again. Not a single member of the latter population that came to the ER for something other than violent injury ever sought medical care for any kind of serious assault.

The Annals issue containing the study on violent recidivism also held an editorial in which eight of the major medical associations (ACP, AECP, AAP, ACS, etc.,) called for stronger physician commitment and endorsed a list of public health initiatives to deal with the medical risks of guns.  But I think that physicians need to do more than just support public health strategies in this regard.  What they really should do is develop effective medical strategies based on research like the articles cited above.  After all, it’s ultimately what the doctor tells the patient which makes any difference at all.

Gun Trafficking in America - coverOn sale at Amazon.

 

Now We Finally Know Why Those Gun-Grabbing Doctors Ask Patients About Guns.

The Woodward News of Woodward, OK, is now running a series of articles based on the ”research” of their staff writer, Rachel Van Horn, as to why physicians are asking patients about gun ownership.  The problem arose in Woodward when a town resident was asked about gun ownership during a routine intake interview conducted before her physical exam.  Of course in this cattle town of 12,000 people it would be difficult to find someone who didn’t own a gun, nevertheless, the patient felt her privacy had been invaded, thus leading to the effort by the News to figure out what’s going on.

docs versus glocks                The issue of physicians and guns just doesn’t seem to want to go away, largely because physicians are becoming more assertive in voicing their concerns about guns, while the gun industry continues its efforts to convince gun owners that the medical establishment is the implacable foe of 2nd Amendment rights.  It’s now routine that every medical society issues a statement deploring gun violence, while the NRA continues its efforts first realized in Florida, the Gunshine State, to prevent physicians from talking to patients about guns.

Given this background, Ms. Van Horn stepped boldly into the controversy, hoping to discover the actual “origins” of the question of gun ownership which now appears routinely on medical questionnaires from Woodard, OK to Washington, D.C. and back again to Woodward.  First she learned that the question is now listed on the various Electronic Medical Records (EMR) intake forms used by most clinicians in the United States.  But none of the companies that produce EMR software would respond to Ms. Van Horn’s requests for information so that was a dead end.  Then she went after the Medicaid and Medicare folks, figuring this might lead her to the nation’s Number One gun-grabber, a.k.a. Obama, but again she came up with a blank.

But then Van Horn found an important clue, because it turns out that the gun ownership question “appears in nearly the exact same format, regardless of which software company produces the program.”  Which means there must be some gun-grabber hiding under a bed somewhere who’s ultimately responsible for this nefarious and evil attempt to disarm the good people of Woodward and everywhere else.  No guarantees, but our intrepid reporter might have unearthed the source, namely, the American Academy of Pediatrics which, according to her research, published a statement in October, 2012 calling for a question on gun ownership to be included in all patient examinations and histories.  Had she bothered to read the actual report, she might have noticed that the same sentence also advised parents “to prevent access to these guns by children.”

I want to talk about this issue of gun access.  This past weekend, a 3-year old in New Mexico grabbed a handgun out of his mother’s purse and shot her and her husband, neither of whom luckily died from their injuries.  Last month in Idaho a 2-year old pulled a gun out of his mother’s purse and shot her to death.  Now I’ll bet you that both of these mothers wouldn’t ever have put their toddler into a car without buckling up the safety harness.  And I guarantee you that their pediatricians would have asked them about seat-belt use during routine medical examinations, and neither of these women would have considered the question to be offensive or an invasion of their privacy.

So what makes asking whether or not someone locks away their guns different?  I’ll tell you what makes it different.  It’s the fantasy that an unsecured gun, as opposed to an unsecured seatbelt doesn’t represent a risk because we need guns to protect us from God knows who or what.  And the gun industry has been promoting this fantasy for the last twenty years without a shred of credible evidence to back it up.  And guess who just happens to have conducted serious and definitive research that indicates the reverse?

 

Physicians Need To Stop Talking Just To Each Other About Guns

Gun owners, particularly the more activist gun owners, tend to be prolific bloggers.  Partly this is because they often believe themselves to be an “oppressed minority,” whose vies on guns aren’t reliably reported by the media; partly because guns still aren’t a “mainstream” item in many areas which prompts gunnies to create their own, alternate communication channels.  You can catch a flavor of this mentality in Brian Patrick’s The National Rifle Association and the Media, a book whose arguments I don’t necessarily agree with, but it nevertheless gives some good  insights into the gun-owning frame of mind.

I make a point of reading several gun blogs every day to keep up with what the “other side” has to say.  Many of the blogs are basically advertising vehicles whose content is comprised mainly of cut-and-paste entries from other blogs or sites.  My personal favorite is CalGuns, which seems to attract a fairly literate audience that not only refrain from much of the in-your-face rhetoric that characterizes so much of the current gun discussion (thanks to Ted Nugent, et. al.) but also gives space to interesting and informed questions that do need to be confronted in the gun debate.

docs versus glocks                For me and many of the readers of my blog, a major issue involves the role of physicians in dealing with the violence caused by guns.  I don’t really think there’s any connection between the NRA’s opposition to Vivek Murthy as Surgeon General and the possible outbreak of Ebola in the United States.  But I do believe that a pernicious trend exists to prohibit medical inquiries about gun ownership now that the Florida gag law has appeared in Missouri and will surely spread beyond.  It’s pernicious first of all because it fosters a wholly uninformed, stupid and reactionary view of the role of physicians in their everyday work, and it’s also pernicious because it is the foundation of a cynical marketing strategy to make consumers believe that guns are just another, all-American way to have fun.  I beg to differ with the NSSF, but the AR-15 just isn’t the Millennial version of the Daisy Red Ryder and we shouldn’t be creating a generation that will hope to find one on Christmas Day sitting under the tree.

In that respect the CalGuns blog posted an interesting thread yesterday that read: “My sister took my niece to the doctor the other day and they asked her if there are firearms in the house. Is that legal in California?”  The writer went on to reference the Florida gag law which, if nothing else, shows that he has some awareness of events beyond himself, and most of the responses he received were also fairly cogent and informed.  One writer differentiated between “legal” as opposed to “appropriate,” another suggested that the patient ask the physician “in a nice manner” why the question was being asked, a third poster stated that he would be concerned that perhaps the doctor suspected “foul play.”

These comments demonstrate to me that there are lots of gun owners who simply don’t understand the reasons why, medically speaking, physicians need to ask patients about access to guns.  And it doesn’t work to simply explain this lack of understanding because of the NRA’s demonizing of physicians over the past twenty years.  It seems to me that physicians, medical organizations and the medical establishment in general need to do a better job of explaining their role and responsibilities in dealing with the violence or potential violence caused by guns.  When the American Academy of Pediatrics publishes a statement about gun violence on their website, do they ask themselves whether the commentary will be picked by the readers of CalGuns?  As long as physicians only talk to other physicians about gun violence the NRA will own the argument about physicians and guns.

The Virus Is Spreading And I’m Not Talking About Ebola

Last month the Missouri legislature passed a new gun law that was essentially a rewrite of a bill vetoed by Governor Jay Nixon.  Missouri has been in the forefront of easing restrictions on gun ownership and this law continues that trend.  In 2007 a decades-old law that required state residents to apply for police permits to purchase handguns was overturned, and the result was an immediate spike in gun homicides.  The new law drops the minimum age for concealed-carry from 21 to 19, allows teachers to bring concealed weapons into schools, and prohibits towns, counties or other local jurisdictions from promulgating gun laws that conflict in any way with state statutes.

According to the law’s sponsor, Republican Senator Will Kraus, the law was designed to protect the rights of gun owners who had “earned” concealed-carry privileges by dint of voting or military service.  Could this guy have a statement that dumb on the floor of the State Senate?  Obviously he did, and he went on to say that a concealed-carry license also gives state residents the right to carry a weapon openly, again because they had “earned’ this right by dint of registering to vote.

docs versus glocks                If the Missouri State Legislature wants to make it easier for state residents to pretend they can keep everyone safe by walking around with a gun, I really don’t care.  Despite the continued mouthings of John Lott and other NRA sycophants, there is simply no credible evidence which proves that legal gun ownership reduces crime.  The good news about concealed-carry is that most people who have a CCW permit actually don’t bother to walk around with a gun, and while CCW on the one hand doesn’t lead to less crime, it also doesn’t seem to spark any great increase in crime on the other.

But what I am concerned about is another part of the law which makes Missouri the second state to gag physicians who try to ask patients about their ownership of guns.  Here’s what the law says: “No health care professional shall be required by law to inquire whether a patient owns or has access to a firearm.”  It then goes on to prohibit physicians from noting gun ownership in a patient  records or disclosing the identity of a gun owner to “any government entity” unless the physician is ordered to disclose such information via court order, blah, blah, blah. The final clause of this section of the law contains the usual bromide about how gun ownership can be discussed if, in the physician’s professional judgement, the patient’s access to a gun might be of medical concern.  But make no mistake about it: Missouri, like Florida, has now instituted a gag order against physicians talking to patients about guns.

What really concerns me about this attack on physicians is not the fact that it has taken place.  Frankly, once those two idiots on the 11th Federal Circuit upheld the Florida law, I assumed that it would be replicated in state after state.  The bigger problem is that I learned about Missouri closing down physician inquiry from reading the text of the Missouri law itself.  When the Florida law was first passed, the Brady Campaign, the American Academy of Pediatrics and a host of other medical groups not only went immediately to court, but kept up a steady drumbeat about the issue and even now are asking that the 11th Circuit’s bizarre decision be overturned.  In the case of Missouri, nobody seems to have noticed that the gag-MD virus has spread.

The real reason that the gunnies want to push physicians out of the discussion about gun violence is not because physicians are opposed to guns.  It’s because the NRA and its allies want to disconnect gun ownership from violence to make their products more acceptable, more enjoyable, more normal for every dad and mom.  After all, we agree that violence is abnormal but guns don’t pose any threat at all.  Isn’t that right, doc?

 

Where Should Americans Learn To Shoot? In School Of Course.

Last week the National Education Association posted a video by Billy Johnson, who does “news commentary” for the NRA.  Despite the disclaimer that the video does not represent the “opinions of other organizations,” the content is the usual NRA-admixture of half-truths, sophomoric clichés and outright lies.  THE NEA gave it front-page coverage because it promotes the idea of universal gun education as part of the normal school curriculum, kind of like driver’s ed and just as necessary as reading, writing and math.

What’s the justification for this nonsense?  According to Johnson, we should be teaching shooting in schools because Americans “need” guns and guns are “good.”  This polite rant reflects an emerging NRA strategy is to reach beyond the organization’s core membership with a broad-based message to drive home the idea of guns as just another, regular consumer product that everyone should own.  After all, once we get past purchasing the absolute necessities each week, don’t our decisions about what else to buy usually reflect only the fact that it’s something we really want?  What’s it going to be this week?  New shoes? New clothes? A new gun?  Let’s go shopping.

             Billy Johnson

Billy Johnson

The NRA messaging is an effort to “normalize” gun ownership, but also reflects their awareness of how Americans increasingly educate themselves, communicate with each other, and thus make decisions about what to buy, own, and otherwise pony up the consumer bucks.  Not only is the whole society moving towards digital and particularly video channels, but the Millennials, the only generation who have yet to decide whether or not they want to own guns, are twice as likely to use Facebook and other social media outlets to make contact and communicate with others.

A bit of recognition of this problem was recently voiced on Huffington Post by Dan Gross, President of the Brady Campaign, who talked about the importance of messaging gun safety by “taking the emotion out of a debate that has gotten all tangled up in the second amendment.”  He cites as a successful effort the joint Brady-American Academy of Pediatrics ASK program that encourages parents to ask if there are unsafe guns in homes where their children visit.  I’m not taking anything away from either organization, but this approach completely misunderstands the NRA whose cavalcade of video commentators not only talk the talk directly to potential gun owners, but also – and here’s the key element – talk specifically about guns.

                Gun control advocates feel comfortable talking about things like safety, background checks, mental health, concealed-carry and the like.  But to the average gun owner or the wannabe gun owner, that’s just so much noise.  The real question the gun control crowd should be asking is simply this: Do you really want to walk around with something which, in an instant, can end a life or change your life in an unalterably terrible way?  But somehow the advocates for more gun control always seem to gloss over the only thing that really makes a difference, and that one thing is the gun.  Meanwhile, the NRA forges ahead on the video playing-field selling the idea that guns are natural and good.  On this issue, the most important issue, the other side doesn’t even field a second-string team.

We have grown accustomed to believing that the size of the gun-owning population is decreasing as the public surveys continue to show a decline in the percentage of households which claim to have guns.  There is also plenty of internet chatter about how the NRA membership claims are vastly over-stated.  Even if this is all true, and I’m not sure it is, the NRA and the gun lobby in general aren’t rolling over and playing dead.  They are out there with their videos, their Facebook pages, their Tweets and the other channels that comprise a new media environment which they completely own. Do you think the other side can catch up?

Surprise! A Study Reveals That Unlocked Guns Are A Health Risk.

Earlier this month The New York Times ran an editorial about a recent study on gun violence and children published by Everytown, aka Moms, aka Bloomberg, et.al.  Like a similar study published this year on mass shootings, the major sources were media reports about unintentional gun deaths of children which, according to this report, is substantially higher than the numbers furnished by the CDC.

The issuance of the report, according to a letter to the Times, coincided with the annual ASK day, which is a collaboration between Brady and the American Academy of Pediatrics (AAP) to encourage safe gun storage in homes with young children.  The ASK campaign has been around for more than ten years and, according to its website has “inspired more than 19 million households” to keep guns away from where children play. Unfortunately, if the numbers of unintentional child deaths from shootings can be believed, the ASK campaign has a long way to go.

everytown logo                I don’t doubt Brady’s claim about reaching 19 million households, although I’m not sure how many of these households either contain guns or keep them around unlocked.  My impression is that very few gun owners are willing to listen to what Brady or Bloomberg has to say, just as there can’t be more than a handful of non-gun owners who are members of the NRA. When all is said and done, this is the real problem in the debate about guns, namely, that the flagship advocacy organizations speak only to their like-minded constituencies, there’s no real communication between adherents on the two sides.

According to the Newtown report, there are 21 states that have no child access prevention (CAP) laws at all.  What this means is that if a kid (or an adult, for that matter) picks up a gun and bangs away, the gun’s owner doesn’t face charges even if someone is injured or killed.  Many of these states are out West, where gun controls have been traditionally lax, but while these states don’t suffer much in the way of unintentional shootings, they do experience higher-than-average gun suicide rates, which might also be mitigated if guns had to be locked up.  On the other hand, Eastern states like Michigan, Ohio and South Carolina all had multiple juvenile deaths from gun accidents, and none of these three states have any CAP laws that might have helped prevent access to guns.

I’ll leave it to Brady to figure out how to mobilize even a portion of those 19 million ASK households to help drive their agenda forward; my primary concern is to look at the role that pediatricians should play in diminishing the health risks of unlocked guns.  Jim Perrin, a co-signer of the New York Times letter and President of the AAP, believes that unlocked guns present the same kind of health risk to children as lead or unattended backyard pools. And he makes the point that just telling children about the risk of guns isn’t enough; kids are naturally curious and in this case curiosity could do a lot more than kill the cat.  After all, many pediatricians ask parents whether they lock children into a car seat before going for a ride.  How much longer does it take to add the word ‘gun’ to a question about locks?

Don’t get me wrong.  I’m not trying to add a minute’s extra work or responsibility to everything that medical professionals are now required to do in the brief time they spend with patients each day.  But the physician’s task is to lessen risk, and no matter what nonsense Rand Paul and the NRA promote about how doctors are a threat to the 2nd Amendment, anyone who believes that an unlocked gun in a home with children isn’t a health risk is presenting a degree of stupidity that no amount of medical care will ever cure.

NRA Takes on the AAP: Have They Lost Their Minds?

aap

 

When the NRA or one of its minions goes after pediatricians, the way they are now going after Doctor Judith Palfrey and the American Academy of Pediatrics, they have fallen off the cliff.  This isn’t just more proof that the leadership has come under some extremist, radical spell.  To me it means they have entered goofy-land.  And it scares me because I’m a member of the NRA.  I don’t like to think that this organization, which I joined in 1955, could now be led by people who have completely lost their minds. The NRA didn’t attack Dr. Palfrey and the AAP directly.  It was done for them by an interesting sub-group called Doctors for Responsible Gun Ownership.  The head of this group, which claims “1,400 doctors, health care professionals, scientists and others nationwide,” is a physician named Timothy Wheeler.  This organization doesn’t even make a pretense of being rooted in science or fact and coming from other physicians,  its attack on Judith Palfrey and the AAP,  is a professional disgrace. According to Dr. Wheeler, Dr. Palfrey “was recently the president of the notoriously anti-gun rights American Academy of Pediatrics (AAP), which urges doctors to pressure their patients to get rid of their guns.” That statement is simply a lie.  This past January, the AAP produced a Policy Statement: “Preventing Firearm-Related Injuries in the Pediatric Population.”  It is the official AAP statement on gun ownership as it relates to the health and welfare of children and it was published after the Sandy Hook massacre.  I am assuming that Dr. Wheeler read this statement which is why I am calling him a liar.  If he didn’t read it, he’s a fake.  Either way, here’s the AAP’s official position on guns:

Counsel parents who possess guns that safe storage (locked

and unloaded) and preventing access to guns reduces injury

(by as much as 70%), and that the presence of a gun

in the home increases the risk for suicide among adolescents.

Physician counseling, when linked with the distribution

of cable locks, increases safer home storage of firearms.

                See anything here about getting rid of guns?  See anything here about not owning guns?  See anything here about being notoriously anti-gun?  Well, I guess that if you believe that leaving guns unlocked around the house makes you anti-gun, then that makes most gun owners, including me, anti-gun.  In the interests of full disclosure, I happen to be married to a pediatrician.  She has no problem with the fact that I own a gun shop because she knows that I understand what gun safety really means.  She knows that I counsel my customers about gun safety the same way she counsels her patients.  I guess this makes us both anti-gun, right Dr. Wheeler? Judith Palfrey is among the most respected, eminent pediatricians in the United States.  She has passionately and pragmatically argued for child health priorities over a long and distinguished career.  She deserves a seat at any table when the issue of gun safety is discussed.  What she doesn’t deserve is to have her views distorted by a toady for the NRA.  The NRA leadership can reclaim their credibility by renouncing Timothy Wheeler’s reckless and false statements.  They don’t need to look for enemies under every bed.  They need to come out from the extremist rock under which they have crawled, join with groups like Evolve and contribute to finding sensible solutions to gun violence.