Gun safety: What can you do?

September 1, 2016

Time and ability may put a damper on a pediatrician’s ability to assess a patient’s risk of a gun-related injury, even though most say prevention of firearm injuries is a priority.

Most pediatricians agree that it’s important to ask parents if they keep guns in the home, and to then offer guidance on gun safety as needed. Few, however, actually have the time for these questions.

“Nobody likes to talk about giving a shot for immunizations, either. However, we would be remiss if we didn’t, and we have to talk about the gun discussion the same way,” urges Michael Hirsh, MD, professor of surgery and pediatrics at the University of Massachusetts Medical School in Worcester, and an advocate of gun violence prevention.

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Hirsh’s comments echo the sentiments expressed in a survey conducted by the American Academy of Pediatrics (AAP) that reveals new information about how pediatricians address gun safety.

According to the latest AAP Periodic Survey of Fellows, the majority of pediatricians say preventing gun violence should be a priority for all practitioners. More than half, 55%, of pediatricians reported that gun violence was a problem in the communities they serve, and that 1 in 7 had treated a gun injury during the previous year. Inner-city pediatricians were most likely to report gun injuries, at 26%, compared with 10% of rural and 6% of suburban pediatricians.

Whereas 70% of pediatricians polled reported that they were comfortable discussing gun safety with patients, only about 20% said they actually have the time to do so. The majority of pediatricians reported that they can identify which families have firearms in the home through health supervision counseling, and recommend to those families that the guns be unloaded and locked up, but 36% of pediatricians said parents resent being asked about firearms.

That sentiment is affirmed in another new study from the Colorado School of Public Health at the University of Colorado, Aurora. That national study revealed that 66% of roughly 4000 Americans polled believe that it is sometimes appropriate for a physician to ask a patient about firearms. The rest, however, believed it was never appropriate. About a third of the respondents had children living in their home and 35% owned 1 or more guns.

The researchers suggest that questions about firearms are acceptable from the patient’s perspective when there is some sort of medical reason for the question, but in pediatrics, firearms may pose a more indirect threat.

Unintentional injury is the leading cause of death in persons aged 1 to 44 years, according to the Centers for Disease Control and Prevention, with homicide, suicide, and accident by firearm among the top causes of injury.

More than 17,000 children are killed or injured by guns each year, with an average of 8 children unintentionally being shot each day, according to the nonprofit Brady Campaign to Prevent Gun Violence. Eighty percent of those accidental gun injuries happen at home, and an estimated 1.7 million children and teenagers live in a home with a loaded, unlocked gun.

The collaborative Brady Campaign/AAP initiative ASK (Asking Saves Kids) program urges parents to ask whether there is a gun in the homes their children visit. Although parents who own guns might think they are hidden, the Brady Campaign says 3 out of 4 children know where the “hidden” gun is in their home.

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Gun avoidance and gun education aimed at children isn’t particularly effective in preventing gun-related deaths among children, and may even increase gun handling among children, according an AAP report. Programs aimed at parents, however-such as keeping guns unloaded or locked up-are more than 70% effective in reducing both unintentional injury and suicide by firearm in children and teenagers, the study found. The AAP also advocates the Connected Kids violence prevention program and the use of the previsit questionnaires that address gun safety in the Bright Futures toolbox. The AAP offers other guidance on gun safety as well, and urges pediatricians to ask caregivers about access and availability of firearms and counsel them on gun safety accordingly. However, in some areas, that has become increasingly difficult.

A law created as a result of a new patient encounter that went terribly wrong in Ocala, Florida, in 2010 is one such example. A pediatrician asked a new patient about guns in the home, but that patient was offended by the question and quickly involved the local press, and eventually lawmakers, Hirsh says.

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The bill that was crafted as a result of the incident-the Privacy of Firearm Owners Act of 2011-prevents physicians from asking patients about guns. The wording of the law does not completely prevent physicians from asking about guns, but orders them to “refrain” from asking about guns in the home unless they believe “in good faith” that the matter is important for medical care or safety. Physicians are also prevented from entering information about firearms into a patient’s medical record unless it is relevant to their care or safety.

Numerous medical groups oppose the so-called “gun gag law,” with the American Medical Association (AMA) calling it “an unconstitutional attack on the patient-physician relationship and the free speech necessary for the practice of medicine.”

The heavily opposed law stayed locked in the legislature until the last minute, when it was passed as a result of the penalty for breaking the law being reduced from a third-degree felony to a misdemeanor, fine, and possible loss of licensure.

The law, despite offering exceptions, creates a danger zone for physicians, whose intentions in asking about a gun in the home could be left to interpretation and possibly land the physician in legal trouble.

Immediately after the passage of the law, numerous lawsuits were filed in appeal. A federal injunction was granted pending the outcome of the appeals process and is still in effect, but it has had a “chilling effect” on physicians in Florida, Hirsh says.

“It’s working the way it was intended even though it’s not being enforced,” Hirsh says.

The last hearing on the appeal was in June this year, just days after a deadly shooting in an Orlando nightclub. No decision has been released as a result of that hearing, but Hirsh says there is cautious optimism that the climate is right in Florida for the law to be overturned.

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“The main argument is that the second amendment right of gun owners trumps the first amendment right of the doctor,” Hirsh says. “The doctor/patient interview is believed to be sacrosanct and it’s perfectly within a patient’s right not to answer. However, if you don’t grant the doctor first amendment rights, that’s a discrimination beyond just the doctor’s office.”

Hirsh says there’s also an argument that questioning patients or their families about guns is intimidating.

“That would be like saying that asking if you use fluoride in your toothpaste is intimidating. People have to cede to the doctor that we know what we’re doing and cede to the patient if they are not comfortable with the questioning [and] they tell the doctor that,” Hirsh says. “We’re supposed to be promoting wellness and these preventive questions are so critical to that.”

Sixteen other legislatures have considered bills similar to Florida’s, Hirsh says, and Texas and Missouri have passed similar measures that are now on hold pending the outcome of the legal battle in Florida.

Hirsh, who founded the Goods for Guns gun buyback program, has a passion for preventing gun violence. After 3 decades as a pediatric trauma surgeon, Hirsh estimates he has operated on dozens of children injured by firearms. His program offers between $25 and $75 in gift cards for guns that are turned in around Worcester, and has collected more than 3000 guns.

Although guns in the home are 22 times more likely to kill a family member or friend than an intruder, Hirsh says he no longer believes it’s realistic to expect people to give up their guns completely.

“I got away from my more idealistic days when I thought we could get rid of more guns to reduce the means to a low. I don’t think that’s feasible anymore. With 350 million weapons in circulation, we’re never going to eliminate guns, nor do we have to. We just have to be sensible and adapt to their presence,” Hirsh says.

Hirsh is now working with a gun safety expert and a group of physicians and other stakeholders to develop a new toolkit for physicians that will provide them with more meaningful tools for practice.

“Right now, a lot of pediatricians say if they ask the question, what do they do with the answer?” Hirsh says.

The toolkit should provide answers to various situations and hopefully provide pediatricians with resources, such as trigger locks that could be passed out to gun owners to provide at least temporary security to a gun in the home.

Hirsh is also working with mental health professionals to help identify ways to take guns-even temporarily-out of the hands of individuals at risk of suicide.

“Fifty percent of gun fatalities are from suicide, and if you follow this carefully you see time and time again comments from neighbors and friends saying ‘we knew he was depressed, but we never thought he would take the next step,’” Hirsh says. “If you know a person is depressed and you know they have a gun, right now there is no mechanism for doing something about that.”

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The legal and logistical concerns about transferring guns in a time of crisis are complex, but Hirsh says he is working with the attorney general’s office in Massachusetts and with gun owners and dealers to come up with a sort of gun repository where a neutral party could temporarily hold weapons for an individual in a state of crisis.

Hirsh says he also strongly supports the Connected Kids curriculum and its assertion that the 3 most important things a pediatrician can ask parents is whether they use vehicle restraints when they travel with their children; if they have a smoke alarm; and if there is a gun in the home.

“Motor vehicle crashes this year will for the first time be lower than gun fatalities. We’ve done so much to try to get on top of the motor vehicle as the source for injury with multipronged approaches but we haven’t really done anything like that for guns,” Hirsh says. “I think we have to come up with ways to secure the guns better in the home; to identify the folks that own guns that shouldn’t have access to them for at least a short period of time; to help parents childproof their home; and to make sure that terrorists don’t get guns.”