Who’s To Say Whether I Should Carry A Gun?

The NRA decided years ago that there’s no seat at the table for physicians when the committee hearing or the funding agency gets together to talk about guns.  They don’t even want physicians talking to their own patients about guns and they certainly don’t want the Surgeon General  ever to say anything about guns. But while such aggrieved nonsense may play well with the NRA faithful, particularly repeated by a putative Presidential candidate, those who live in the real world know that we all need a physician when it comes time to make critical decisions about our health.

One of the critical health decisions for which people might need medical counsel is whether or not to carry a gun. Now I know that the pistoleros who spend every vacation sharpening their skills at shoot-em-up amusement parks like Gunsite or Thunder Ranch don’t need help deciding whether their eye-hand coordination will let them emerge victorious from the fray, but there must be plenty of people among the eight million Americans now holding CCW privileges who don’t have the physical or mental dexterity that handling a lethal weapon requires.

paul                Even though a majority of now states issue CCW on a “shall” (required) rather than a “may” (discretionary) basis, there are hardly any states that do not grant the official issuing CCW the authority to deny a permit if the applicant, regardless of legal background, might use a weapon to endanger himself or someone else.  The NRA would probably say that one of their local members should be consulted in cases like this, but you and I know that the licensing authorities will turn to a physician because a doctor is the only professional they can really trust.

But this brings up a little problem.  Because it turns out that many physicians don’t trust themselves to make competency decisions about whether people should own or carry guns.  The American College of Physicians conducted a poll which revealed that two-thirds of its members didn’t counsel their patients on firearms because they didn’t know enough about how to treat patients at risk for misusing their guns.  A similar poll conducted by the American College of Emergency Physicians in 2013 said the same thing.

We now have a new poll that asked physicians in North Carolina whether they felt comfortable responding to requests from county sheriffs who needed to verify the physical or mental competency of someone wanting to carry a gun. This poll, of whom one-third of the respondents indicated they owned guns, found that 60% of the physicians did not feel they could “adequately assess” whether their patient was physically capable of carrying and using a concealed gun, and nearly 50% felt they could not determine CCW competency on mental grounds.  As for those who think that the medical profession has been cowed into submission by the lunacies of a self-certified Kentucky opthamologist and a small, pro-gun fringe, a majority of the respondents did not believe that the doctor-patient relationship would suffer if they didn’t certify the patient as being fit to carry a gun.

The real knowledge deficit created by defunding CDC gun research is not whether guns are a medical risk.  The bigger issue is the fact that, when confronted with a patient possibly at risk to commit (or be the victim of) gun violence, many physicians don’t know what to say or do. Now that the American Medical Association has just endorsed the idea of medically-accredited gun violence education, perhaps the gap will begin to close.  And if anyone out there thinks their physician is now their enemy because he wants to talk about guns, perhaps you should make an appointment for your next checkup with Doctor Rand Paul.


When It Comes To Guns, Physicians Need To Do What They Do Best – Be Physicians.

The American College of Physicians has just released a survey covering attitudes of its members towards  gun violence.  This was the second survey conducted by the ACP on medical attitudes towards guns, the previous having been published in 1998.  In the earlier survey, while 90% of the respondents believed gun violence to be a public health issue, less than 20% stated that they engaged in prevention counseling with patients.  The feedback from the most recent  survey was similar; most physicians consider gun violence an even bigger medical problem than they did previously, but a majority still do not consider themselves willing or able to intervene with patients who present evidence of being at risk for violent behavior with guns. In fact, three-quarters of the respondents said there was a need for more education of physicians to help them counsel patients in firearm injury prevention.

acpThe survey results reported by the ACP are similar to feedback from other medical specialists.  In 2013 The American College of Emergency Physicians also published a survey on how emergency physicians felt about gun violence patients and, like the ACP, found that the vast majority of emergency physicians had never been formally trained regarding firearm safety counseling and did not believe that patients would see them as credible sources for gun counseling.

Gun violence appears to be the one public health issue for which physicians have not developed very clear guidelines for counseling and/or treatment.  In fact, there is no medical agency or association that has even issued a protocol for identifying patients who might be at risk for gun violence, either as perpetrators or victims.  While we know everything about gun violence victims after they are shot, physicians do not have the knowledge to appropriately intervene before the violence takes place.  Lacking the kinds of treatment guidelines that exist for other public health issues like obesity, smoking or substance abuse, physicians are forced to pretend that gun violence as a clinical issue doesn’t exist.

The ACP survey was followed by a Policy Position Paper in which the organization listed nine recommendations to help prevent gun violence and only the first two recommendations covered practice and counseling methods for physicians to follow in treating patients.  The other seven recommendations covered the usual legal/legislative solutions that have been advanced by every advocacy group that promotes policy initiatives to reduce gun violence.

Everyone should debate and support common-sense legal and legislative solutions to the problem of gun violence, but you don’t need four years of medical school followed by an internship and a residency to figure out how to advocate against guns.  What physicians should and must bring to the debate is exactly what they are not doing now, namely, using their unique skills and their equally-unique relationships with patients to deal with gun violence as a medical issue for which interventional counseling might yield significant results.

In a paper published last year, Shannon Fratteroli and colleagues pointed out that the greatest value of joining advocacy to medical treatment in discussions about gun violence is the fact that physicians are trained to communicate with patients about fear, they are “accustomed to helping people manage their fear of disease and death.”  As so much of the current gun debate is generated by fear – fear of crime, fear of violence, fear of government – physicians should bring their clinical experiences in managing fear to this debate and thus provide patients with sound and effective alternatives to using a gun.



The NRA Has Found a New Physician Friend

eagleRecently the medical news service Medscape published a video editorial about gun safety by Art Caplan, who runs the Division of Ethics at NYU’s Langone School of Medicine. The editorial content was hardly unique or different from similar statements that have been made by virtually every major medical society, namely, that the existence of several hundred million guns constitutes a health risk that cannot simply be ignored because of a 2nd-Amendment right to own a gun.

Caplan’s editorial has just been challenged on Medscape by Dr. Gregory Hood, an internist from Kentucky, who’s a rising star in the medical establishment, having just been named Governor of the Kentucky Chapter of the American College of Physicians.  Incidentally, the ACP  stated that “physicians need to be able to have frank discussions with their patients and parents of patients about firearm safety issues and risks to help them safeguard their families from accidents,” in a letter sent to the U.S. Senate during the debate over a new gun law following Sandy Hook.

While there appears to be a consensus among Dr. Hood’s colleagues about medical risks from guns, he evidently doesn’t share their concern.  This is particularly true given the fact that ” there will always be the inevitable threat of acts of violence and terrorism, whether by guns, fists, or other measures,” against which, according to Doctor Hood, “we must acknowledge the inherent right of law-abiding citizens to take reasonable precautions against such threats.”  The issue isn’t hundreds of published, peer-reviewed articles that show a link between access to guns, safely stored or not, and medical risk.  The real problem is allowing the good, law-abiding citizen the right to protect himself from terrorism with a gun.

What really seems to bother Dr. Hood is his belief, probably true, that most physicians have little first-hand knowledge about firearms and therefore risk violating best practices by counseling patients about an issue for which they cannot be considered to have much objective knowledge.  But that’s not a problem because medical professionals can always turn for guidance to the real experts on gun safety, namely the NRA.  According to Dr. Hood, the NRA’s Eddie Eagle program has “instructed” more than 25 million children in gun safety since 1988, and the program’s signature phrase, “STOP. Don’t Touch. Leave the Area. Tell an Adult” shouldn’t be bandied about by well-meaning researchers like Art Caplan and various medical professionals who aren’t skilled in the ways and means of guns.

If it were the case that Dr. Hood was just a flack for the NRA I could forgive his flight into fantasy about the NRA’s commitment to gun safety and let it go at that.  But Gregory Hood has an impeccable educational background, he’s obviously trusted and respected by patients and peers, his voice and opinions carry some weight inside and outside his profession.  So I’m going to take his comments very seriously and reply to them in a direct and serious way.

The fact is that the NRA has absolutely no idea whether a single child has ever been “instructed” in gun safety either in school or at home.  Hood’s figure of 25 million children comes from the NRA, it has never been validated by an independent source, and it is based on the number of Eddie Eagle pamphlets that the NRA claims it has mailed out over the last twenty-five years. That’s not instructing anyone in anything, and Hood should be embarrassed for pretending that this “program” does anything more than promote the NRA.

I really wish that guys like Greg Hood would stop hiding behind their cloak of professional integrity and admit, once and for all, that their primary interest is in protecting the access of their patients to guns.  I have no quarrel with that position, incidentally, because if you haven’t figured it out by now, I’m a gun owner myself.  But if we are ever going to have a serious and honest debate about whether guns are a public health risk then everyone has to come clean.  At this point Dr. Hood needs to be a little more candid about the reasons for his concerns about guns.