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Invited Commentary
August 6, 2021

Opening the Door to a Discussion on Gun Safety

Author Affiliations
  • 1Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 2Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
JAMA Health Forum. 2021;2(8):e211586. doi:10.1001/jamahealthforum.2021.1586

Counseling patients on health risks and behaviors is a core competency for all clinicians. Patients are frequently presented with questionnaires assessing their use of seatbelts or the presence of stairs in their homes to help facilitate these discussions—encouraging patients to use appropriate safety seats for children or preventing falls for older adults. The same should be true for firearm safety, given that according to the Centers for Disease Control and Prevention, about 40 000 people die each year from firearm injuries, most of which are suicides.1 However, studies consistently show that physicians rarely ask about any aspect of firearm safety in health maintenance visits. Indeed, only about 20% of pediatricians ask more than 5% of their patients about gun ownership.2

In their Original Investigation in this issue of JAMA Health Forum, Dr Richards and colleagues3 present a cross-sectional study evaluating patients’ self-reporting of firearm access on a questionnaire administered in a primary care or outpatient mental health setting. They found that most patients responded to the question in this format: more than 80% responded in a primary care setting, and more than 90% responded in a mental health care setting.

Physicians are legally allowed to counsel patients on gun safety in all states. The Patient Protection and Affordable Care Act prohibits required collection of information related to firearms but does not restrict firearm-related counseling between clinicians and patients,4 and after the Florida Firearm Owners’ Privacy Act was overturned as a violation of physicians’ First Amendment rights, no state statute regulates clinician-patient discussions on firearms.5,6

Asking this basic question is an important means by which clinicians can begin to understand firearm ownership among their patients. When clinicians were surveyed on what aspects of firearm safety education were most needed and would be most useful, they often requested specific language to use when talking to families.7 While we need a validated framework for how clinicians can approach these sensitive conversations, posing questions in a printed format is clearly an acceptable option. A simple questionnaire is an easy, efficient, and effective means of gathering important patient information. Especially for clinicians who may feel less confident asking these questions, this allows them to pose questions in a way that is respectful and nonjudgmental.

Inquiring about firearm access on a questionnaire opens the door to a potentially lifesaving discussion of firearm safety, but clinicians must step through it. Dr Richards and colleagues3 found that about 20% of patients in a primary care setting and 15% of patients in a mental health care setting reported having access to a firearm. If we screen, we must also be prepared to intervene. A questionnaire identifying gun-owning patients must be followed by tailored, risk-based counseling. Unfortunately, clinicians are currently ill equipped to provide this counseling, with only about 20% of pediatric residents in 1 survey reporting that they had ever received any didactic education on firearm injury.7

As a clinic prepares to include a question about firearm access in its standard health monitoring questionnaire, consideration must be given to equipping clinicians with the tools they need to respond to positive screens. What are the relevant policies in that state, especially those related to safe storage or protection of individuals at imminent risk of harm to self or others? What other risk factors are present? For example, are there young children in the home with an unsafely stored firearm, or is the patient a victim of intimate partner violence, or has this patient recently been hospitalized for depression? Efforts are underway to design curricula and educational programming for clinicians to help meet this critical educational need.

Asking a question about access to firearms can be the first step to saving a life. Coupling a feasible and effective screening strategy, such as that proposed by Dr Richards and colleagues,3 with a rigorous and evidence-based educational program will help clinicians cross the threshold to becoming competent and confident counselors.

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Article Information

Published: August 6, 2021. doi:10.1001/jamahealthforum.2021.1586

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Hoops KEM. JAMA Health Forum.

Corresponding Author: Katherine E. M. Hoops, MD, MPH, Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children’s Center, 1800 Orleans St, Ste 6349J, Baltimore, MD 21287 (khoops1@jh.edu).

Conflict of Interest Disclosures: None reported.

References
1.
Weinberger  SE, Hoyt  DB, Lawrence  HC  III,  et al.  Firearm-related injury and death in the United States: a call to action from 8 health professional organizations and the American Bar Association.   Ann Intern Med. 2015;162(7):513-516. doi:10.7326/M15-0337PubMedGoogle ScholarCrossref
2.
Grossman  DC, Mang  K, Rivara  FP.  Firearm injury prevention counseling by pediatricians and family physicians. practices and beliefs.   Arch Pediatr Adolesc Med. 1995;149(9):973-977. doi:10.1001/archpedi.1995.02170220039005PubMedGoogle ScholarCrossref
3.
Richards  JE, Kuo  E, Stewart  C,  et al.  Self-reported access to firearms among patients receiving care for mental health and substance use.   JAMA Health Forum. 2021;2(8):e211973. doi:10.1001/jamahealthforum.2021.1973Google Scholar
4.
Patient Protection and Affordable Care Act, 42 USC § 18001 (2010).
5.
Wollschlaeger v Governor of Florida, 797 F3d 859 (11th Cir 2016).
6.
Wintemute  GJ, Betz  ME, Ranney  ML.  Yes, you can: physicians, patients, and firearms.   Ann Intern Med. 2016;165(3):205-213. doi:10.7326/M15-2905PubMedGoogle ScholarCrossref
7.
Hoops  K, Crifasi  C.  Pediatric resident firearm-related anticipatory guidance: why are we still not talking about guns?   Prev Med. 2019;124:29-32. doi:10.1016/j.ypmed.2019.04.020PubMedGoogle ScholarCrossref
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