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.

 

 

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Docs Versus Glocks – Round 2 About To Begin

In 2011 the Florida legislature passed a law to protect the state’s gun owners from having to divulge any information about gun ownership during the course of a medical exam.  The law, which became known as ‘Docs Versus Glocks,’ soon became one of the main poster children of the pro-gun, anti-gun argument that really heated up after the carnage at Sandy Hook.  On one side stood the NRA, which touted the law as a defense of 2nd Amendment rights; on the other side was Brady and the medical community which viewed the law as interfering with the doctor’s right to know.  The law was struck down in 2012 by a Federal District Judge and was immediately appealed by the Gunshine State to the 11th Circuit which held a hearing in July, 2013.  Everyone’s expecting a ruling soon so I thought I would take the opportunity to discuss the case before all the real experts get into the act.

logomdThe law doesn’t completely deny physicians the ability to talk to patients about guns.  What the law actually says is that a physician “shall refrain” from inquiring about firearm ownership unless the practitioner “in good faith believes  that this information is relevant to the patient’s medical care or safety, or the safety of others….” Yet despite this caveat, the medical community attacked the law, declaring that its language would have a chilling effect on the ability of physicians to talk to their patients about all kinds of safety and health issues, not just about guns.  The District Court sided with the docs, calling the law a “legislative illusion” because there was no connection between questions asked about gun ownership and protecting the 2nd Amendment right to own guns.

logo glockWhile arguments over gun control at the federal level get all the headlines, it’s what happens at the state and local levels that really determines whether or not gun owners can get or keep their guns.  The Sullivan Law has been in existence since 1908, it’s almost impossible to own or carry a gun in New York City and 2nd Amendment ‘rights’ can go fly a kite.  In total dollars the NRA gives out less than half a million to state-level candidates and parties, but this is 30 times more than gun control groups give to the same races.  And in a state-level race where 200 or less votes can make the difference, getting your hands on an NRA phone list may carry the day. I’m not sure that the Florida legislators who voted for the gun bill knew or even cared what the law said.  But they didn’t want to be ‘scored’ by the NRA in the next election because they voted the wrong way.  Before the Tea Party showed up it really didn’t matter whether a Republican toed the line on gun issues because the NRA wasn’t about to support any Blue candidates anyway.  But now that a growing number of Republican office-holders face primary challenges from the Right, everyone on the Red side of the aisle is listening to the NRA.

As for doctors, it took them nearly a century after 1850 to become a self-regulating profession whose guidelines for practice and behavior were largely established and maintained by themselves.  And even though their professional autonomy has of late come into conflict with the market imperatives of insurors and other for-profit enterprises, they still retain sovereignty over defining how to deliver their services at the point that such services matter most, namely, in consultations with patients.  The fact that the Florida legislature didn’t bother to ask their own state Health Department for a recommendation on physicians talking to patients about guns tells me that the motive behind the law had nothing to do with concerns about the delivery of health care at all.  For that matter, it wasn’t that the law threatened doctors who talked to their patients about guns per se, it was the fact that any law which infringes on the professional autonomy of physicians to communicate with their patients threatens the validity of the Hippocratic Oath.

Let’s hope that the 11th Circuit understands what this argument is really all about.