June 22nd, 2016
Gun Violence — A Public Health Crisis
Elizabeth Donahue, RN, MSN, NP-C
Elizabeth Donahue, RN, MSN, NP-C, practices adult primary care medicine in Boston, MA.
Often, in a primary care office, it can feel as though we are providing care within a “bubble” of sorts. Appointments are made within the hours of operation of the office, scripts are followed by all levels of staff in obtaining information, and often chief complaints are worked up using the same pattern: obtaining a history, performing an exam, and making a treatment plan. Every now and then, an unexpected finding presents itself, or a rare diagnosis is uncovered. But for the most part, we can take comfort in a routine that is mostly unaffected by what happens outside the four walls of our office.
On Monday, June 13, the familiar (in the wake of the Pulse Nightclub shootings) gave me pause. I asked my first patient of the day a question I had posed to hundreds of patients before her, but on that Monday morning, I nearly spat out the words: “Do you or does anyone in your home own a gun?” Maybe I imagined it, but I could have sworn that my patient gave a slight shiver before responding with a quiet but emphatic, “No, absolutely not.”
As people who provide health care, we ask multiple emotionally charged and personal questions every day. We ask patients about their alcohol use, their sexual activity, their history of domestic abuse, their family, and all kinds of other things within the context of understanding their risks and in trying to prevent and treat physical and mental illness. But in light of the violence in Orlando and the subsequent national discussion, I found myself wondering— how many providers are posing questions about firearms to their patients?
I am trained in family medicine, and in the first two (most sleepless) years of my practice, I had the opportunity to see patients across the lifespan. I really enjoyed working with pediatric patients during this time. I cared for a lot of adolescents, who were honest and, frankly, unfiltered in a way that adults are not. It was one of those adolescent patients who put me face-to-face with the reality of what a gun can do to a human being. I saw her in follow-up of an accidental gunshot wound to her dominant hand. She matter-of-factly described the events of a night out with friends that led her to be in the wrong place at the wrong time, and whereby she became an innocent bystander in a shootout. As we monitored her course over months, her story alternated between how “lucky” she was to have sustained minimal injuries (someone else in the incident had lost their life to the same spray of bullets) and frustration at her lack of progress in recovering. She had lost significant mobility and suffered nerve damage. And the physical wounds, according to her mother and advocate, were nothing compared with her frequent nightmares and setbacks at school and socially. I felt the same empathy for her that I feel for patients who have also suffered any accident or illness that occurs randomly and causes everyone to ask, “why?”
This patient, along with all of my patients under age 18, was asked to complete a safety screening form at every annual visit that includes the question, “Do you or anyone in your home own a gun?” But what about adult patients? Likely out of habit, I have continued to screen every patient in the last 6 years for the presence of a gun in the home, and now my EMR prompts this question in a section on “social history.” Why do we ask? Because we might be able to advise a change in behavior that can prevent a dangerous outcome. When I ask a patient this question, it can prompt a discussion with those who do own a firearm. The discussion is not aimed at removing guns from their owners, but simply at ensuring that a household is safe. Sometimes a patient hasn’t thought about locking their guns, or about storing them unloaded and keeping their ammunition in a separate location. Sometimes a patient hasn’t thought about their children — about how their age and inherent curiosity can present a safety risk. Sometimes a patient hasn’t thought about the implication of owning a gun while living with a family member who has mental health issues. I believe it is my job to have these conversations — in the same way that I ask patients about seat belt use, substance abuse, contraception options, and other things that could affect their health and safety. I do not ask in order to make a judgment of the patient, but in an attempt to uncover information that could help me to best care for him or her.
I also believe that it is part of my job as a care provider to be engaged in learning and advocating about issues of health and safety. When a patient suffers from gun violence, we understand part of the “why” — pathology, forensics, etc. piece together the effects of a gunshot wound. But we don’t seem to have enough research, data, or funding to truly understand “why” on a bigger level. Because of a lack of knowledge, it is difficult to make changes or recommendations to decrease the possibility of a gun-related death or injury. The American Medical Association recently declared gun violence a public health crisis, and also declared their intent to lobby for a lifting of the ban on gun violence research imposed on the CDC. The American Nurses Association defended healthcare providers against suggested “gag rules” that would have prevented professionals from discussing gun safety with patients after the Sandy Hook Elementary School shooting in 2012. I support these professional organizations tasked with improving public health in their attempts to support meaningful changes that could reduce gun violence in our country.
In the meantime, I’ll keep asking my patients about guns in their homes and counseling them on how to be safe in the presence of guns and when to consider removing a gun from a home where there is increased risk for its unintended use.
Thus far in 2016, 6232 people have died due to gun violence. Nearly 1600 of those deaths represent children under the age of 18. Could any one of these lives lost have been saved by a conversation between a provider and a patient? I can’t answer that question, but I do think it’s worth our time to ask, just in case.
Notes and Links:
Yesterday, June 21st marked National ASK “Asking Saves Kids” Day. To learn more about this campaign designed to promote children’s safety click here:
To learn more about the recent AMA position on gun violence after the Pulse Nightclub shooting click here:
To learn about ongoing discussions about funding and provider discussions regarding gun safety after the Sandy Hook Elementary School Shooting in 2012, click here:
24 Responses to “Gun Violence — A Public Health Crisis”
NP/PA Bloggers
Elizabeth Donahue, RN, MSN, NP‑C
Alexandra Godfrey, BSc PT, MS PA‑C
Emily F. Moore, RN, MSN, CPNP‑PC, CCRN
Advanced practice clinicians treating patients in a variety of settings and specialties
Learn more about In Practice: Reflections from NPs and PAs.
The officers of the AMA, APhA, APHA, ASHP, etc., as well as the Surgeon General, need to be seen repeatedly on TV, online, etc. promoting actions of various types be taken against the NRA and gun ownership/violence in general. There are more guns owned (>350,000,000) in the U.S. than there are people. This is absurd and is a prescription for danger and unnecessary deaths. Millennials (age 18-25) own fewer guns than paranoid, stupid middle-aged and older people. Education is needed.
(I’m an old person but have never owned a gun.)
Wayne, you hit the nail on the head. Sadly the anti gun crowd has no clue as to what the second amendment was implemented for. The reality is no swimming pool can stop a government from running amuck, hence zero attention. A well armed populace can. While discussing safety precautions etc is important for our patients, We as a populace need not forget all the genocide committed throughout history that was preceded by gun control. A simple google search would enlighten one. Sadly new laws do nothing to change the criminal or crime, it only restricts those who abide by the law.
Thanks for reading Dr. Simpson and sharing your perspective. I clearly agree that more education is needed at a personal level (between providers and patients) and I also believe more understanding is needed about guns, their use and their effects, hence the import of lifting the ban on CDC research on guns and their implications on public safety. We cannot fully address this issue without a better understanding – we have an evidence base for almost everything else we do in medicine and we need to move toward that standard when it comes to this particular health/safety issue.
I ask my patients about guns at well visits also. I mention using eye and ear protection when using them and keeping them away from children. I tell minors they shouldn’t touch guns unless in the presence of an adult. In my practice I would say about 75-80% of my patients have a firearm in the home. I spend a few moments discussing recommended gun safety at visits, but I spend much more time discussing mental health and alcohol/drugs. They are much higher yield lines of questioning that are much more likely to help patients.
While it is sensible to mention it depending on your population – if you want to hit the biggest risks to children and/or adults – your time is better spent discussing ETOH/Drugs, depression, and swimming pools. In fact, MMWR numbers from 2000-2009 on swimming pools and gun violence showed a rate of ~8 children drown per 100k homes with swimming pools. The number of accidental firearm discharge pediatric deaths per 100k homes with firearms? ~1.5.
The reason there isn’t a national uproar about accidental drownings is in part because it isn’t news. There is little shock value and it doesn’t drive page hits or paper sales. I can recall at least 2-3 children who were accidentally shot in the news in the last few months – but never heard about the likely 6x that number that drowned in a swimming pool. I assume this is why many jump on the public health implications of firearms so heartily but don’t think nearly as much of the higher incident problems. Those high incident problems aren’t plastered across billboards or newspapers daily – if they were maybe we would address them more thoroughly.
True Wayne – but if the topic is public health – lack of exercise, diet, car driving/use, = tens of thousands of deaths/100K population from heart disease and cancer. I understand according to criminal and civil (Food Disparagement) laws in many US states it is illegal to even comment (negatively) on foods health impacts?
After the pharmaceutical giant Bayer tweeted a Vox article that referenced the often cited statistic that eating meat-free “can cut your food carbon footprint in half,” the Big Ag lobby raised its pitchforks in protest. Bayer promptly deleted the tweet and put its tail between its legs: “The livestock industry feeds our planet & we’re glad to support it. It was never our intention to antagonize it—sorry!”
(today’s June 24th 2016 USA example)
Hi Wayne – thanks for reading. I have to say that I don’t think safety screening is an “either/or” discussion but that in especially this case, screening is a “yes, and also” proposition. If this post were about the questions I pose to every patient about every safety issue, it would have gone over the word limit suggested by my editors (similar to the way all of my visits run over by the time I complete all the actual recommended screening for safety and preventable disease!). When I worked in pediatrics, I asked about helmets, seat belts, texting and driving, water safety, safe and respectful dating relationships and so many more issues. And rest assured, every one of my current patients undergo screening for mental health conditions and for the use of drugs and alcohol at each visit – I also believe that these are important issues and are likely not discussed as often as they deserve to be. Feel free to read on to understand how strongly I feel that folks in primary care should be asking and addressing substance use disorder in their visits. http://blogs.jwatch.org/frontlines-clinical-medicine/2016/04/13/how-do-you-treat-an-epidemic/
So please do not assume that just because I wrote about this particular question, that it’s the only one that I ask or that I have placed its significance above any of the rest of the plethora of issues discussed in a primary care visit. It happens to be something that affected my practice early on and continues to more than I would like to see. It also happens to be at the center of our national discourse at the moment. It is for all these reasons, and not for “page hits” that I thought to share my experience.
Sorry Americans – you are the laughing stock of the world. You have a culture based on a lethal/psychotic delusion – the “right” to bear arms – then complain or wonder why so many Americans are murdered/killed accidently – (your choice of words)!. Everyone else in the world gets it. WE agree with everything in this post – as do the 30,000 Americans murdered this year. Would you like sympathy? Sorry – the best I can do is feedback – but after a few dozen decades it’s getting a bit rough to even do that. My best wishes and sad regrets that you will be repeating this post (as other’s have – including your president) until material change evolves, and for that you have my truest sympathy.
Yes, the rest of the world gets it. Only when you do a comparison between the US and a list of countries that perhaps have as diverse population and geography as the US, such as Mexico, the comparison falls apart. The usual method of cherry picking “developed” countries appear routinely to support the premise that the US is the most dangerous place in the world. Take a look at https://mises.org/blog/mistake-only-comparing-us-murder-rates-developed-countries for a different perspective.
Thanks for this reference/link Dan. This is a $20M foundation from Alabama – with “absolute privacy” of it’s donors proclaimed, who spent $600K on fund raising last year. . . . The article states references – but you cannot link to them. . . . .I cannot assess it’s validity any further. . . . .
Max:
Using accurate data is important. The “30,000 Americans murdered this year” figure you mentioned is not accurate.
The U.S. Center for Disease control (2013 data available) lists 16,121 homicides in the U.S., of which 11,208 were committed with firearms. The homicide rate in the U.S. is at @4.5/100,000 population which is still too high, but this is half the homicide rate of 8 to 10/100,000 population which was the norm in the 1970s and 1980s.
Adopting common sense laws, such as universal background checks, would be helpful. But improvements in mental health access and treatment are equally important.
In which country do you reside, or formerly reside?
Joan – I am formerly from Australia – where, in this week’s news, after one assault rifle massacre 20 years ago, Australia banned such weapons – and the death rate since has been. . . . . . . . zero for the entire country. Does this say Australia is a great safety invested culture? – no, but it is data to ponder.
I currently reside in Canada – chosen by many (including Americans) specifically because of this gun issue. Of course Canada has guns, murders and suicides as well as accidents – just at about 1% of the rate of the US a few miles away.
Let’s see if they allow my response as the others seem to be censored.
Max, let’s take a look at your false claims. 30k Americans are NOT murdered by guns, the number is around 11k and has steadily decreased even though the number of firearms in society have increased. Second, the gun itself did not commit the murder, a person did.
On to the next point of contention, “Everyone else in the world” is a broad and all encompassing statement. As a Physician, you should Know better than to say everyone, all, never, always etc. The highest murder rates in the world are in, wait for it, countries that ban guns (think Mexico, Honduras, venezuela etc).
Final point, yes, as a Healthcare provider this topic is one that warrants discussion however as Wayne pointed out, there is far better yield discussing mental health, then potentially breaching the gun subject if one finds cause for concern. The reality is the US is a different country and just because, as you say “everyone else” does something, it does not then mean we should as well.
Excellent points John.
I retract the false claims – as long as you accept that gun damage in the US is MASSIVELY more than many other, otherwise comparable countries.
I am happy to remove the hubris from the “everyone else” claim – as long as you are prepared to accept that it is extremely difficult to see cultural values for their arbitrary or relativistic nature from INSIDE the culture. Americans just do see this a a “gun” issue – THAT is an American culturally sanctioned and supported view. I presume a Spaniard would not call bull fighting “animal cruelty”, as some would not call circumcision “genital mutilation”.
Finally – just because someone does something is certainly no reason to follow – but so is no reason to do something a reason to do it. There is no “reason” for civilian gun ownership, period.
Max,
We actually have no other real countries to compare to. The US is very unique in both its demographics, wealth, population and system of law.
As to the cultural relativism stance, I can concede that point, we are a gun culture predominantly due to our founding principles. We are a country that is supposed to be governed by the people with the intent to empower the people to stop a potential tyrannical government as well as the right to protect ourselves. I know it sounds crazy to some, but that is what has made this country what it is.
As to civilian gun ownership, that is your opinion. There are reasons in my mind and many others to own firearms, one is listed above as well as hunting and self defense. The beauty of this country is you have the right to choose not to own a firearm.
lastly, to the topic at hand, we as providers are on a limited time frame and it is impossible to broach every subject. If you have concern about a patient’s mental health then this may be a very valid and necessary line of questioning.
How easily you speak for the rest of the world. Sadly, you know nothing of what you speak and your opinions are outdated and filled with circumspect and no real facts at all. Americans don’t need your sympathy or your feedback. What qualifies you to offer either. You obviously didn’t pay attention to the bloggers article because your opinion only loosely applies at best. The issue of discussion is not American gun laws, but the screening for gun safety by medical professionals. Take your anti-American rhetoric to a more appropriate site
For point of clarification, the “right” to bear arms, as you wrote, is a) not a cultural basis, and b) not delusional of either the lethal or psychotic flavor. The Right to Bear Arms is a “right” for the civilians of the United States of America to possess the ability to protect themselves from a tyrannical government through armed militia. The people can not be separated from their arms as this offers lasting protection of the Free State. It is not a new concept, in fact, as it was borrowed from the English Bill of Rights.
As to the discussion posed by the blog, I suppose this line of questioning isn’t necessarily inappropriate. However, if i were to screen all of my patient’s on the many, many safety implications that my patients face daily, I wouldn’t have much of the visit time left for the real reason they came to see me in the first place. After discussing drugs. smoking, guns, pools, sunscreen, childproofing the home, proper disposal of medications, etc., etc., the time seems a bit tight. Certainly I could see possibly discussing them on a rotating schedule to address a couple of safety concerns at each subsequent visit, but for some patients, this means the list will take a full decade to broach. You state:
“Could any one of these lives lost have been saved by a conversation between a provider and a patient? I can’t answer that question, but I do think it’s worth our time to ask, just in case.”
But how exactly are you choosing to prioritize your time? Do you choose to give priority to the gun discussion because of personal agenda or because of media poluarity? Because unintentional suffocation, drowning, motor vehicle accidents/pedestrian struck, burns, poisonings and suicides all rank higher based on recent CDC data. In fact, if you remove suicide by firearm and homicide by firearm and really focus only on unintentional firearm related deaths, they only rank in the top 10 for one specific age group, ages 5-9 accounting for 14 deaths in 2014. While safety discussions may remove firearms from the suicide or homicide figures, the intent is likely left unchanged, and really only figure to shift the numbers to other causes of either. So in reference to protecting the lives of our pediatric community from unintentional injury, which of these other safety concerns get dropped to focus on this topic in depth?
I am curious what the numbers would say. If studied, would the numbers reflect that a discussion about such topics (studied individually and collectively) really result in impactful change after the fact? Do patient’s really go home and make safety changes based on my conversations with them in the office? Is there a better way to deliver the message?
I can’t even get them to take their blood pressure medications.
Thanks for these pithy observations Bob. See Dr. Michael Gregor’s top selling book “How Not to Die” for a list of the top (prioritized) preventable disorders and what to do about them. You can process this entire set of risks in a few hours, and present most of them to patients in a few minutes. Many (like the “gun” issue) will be perceived as culturally critical and therefore dismissed by our patients. Many people are offended and even upset by the laws of physiology and simply refuse to engage. Our job is to lead by example (a research validated approach) and support them reaching a more congruent reality based culture of wellness and health – for all (species, parts of the planet, social classes, races etc. etc.). P.S. This makes me a ecological humanitarian – not a socialist, anti-American or communist.
Max, appreciate you reading from what I presume is far away. To be clear, very intentionally this is not a post about the second amendment, gun rights or gun control. Discussions that cover many, many opinions on all of the above from all sides of the issue are widely available on the internet and social media and I believe that the first amendment protects our rights to engage in such conversations. My intent was to raise the point of what role those who provide medical care have in discussing this issue of safety and also in advocating for research to lead to a better understanding of the risks and health implications of gun ownership. I truly believe that taking steps toward more research and better understanding are essential because this is a multi-factorial problem and there is likely not a “silver bullet” solution.
Liz – I get it. Todays editorial in the Economist – that uses phrases such as “wearily familiar”, that physicians are inhibited form gun safety dialogue with citizens, and that ” Gun violence is the product of a set of American choices that, compared to other rich countries, are harmful and extreme” – was noted by me last week. I suggest this may be some validation of or at least consensus on such views.
Calling gun owners, “paranoid, stupid middle-aged and older people” is not only insulting, it is a blatantly false narrative. Of course patients need to be repeatedly “educated” about so many potentially harmful ‘objects’ or dangerous behavior patterns. Let us be committed to education rather than emotional and disparaging dogma.
I’ve been out of primary care for 10 years and never treated children. Were I still practicing primary care, I wouldn’t he asking this question without evidence of efficacy of provider intervention. I’ll spare you the diatribe on pursuit of unproven screening except to say why not order a ca-125 on all your adult women.
That said I’m pretty firmly anti-gun. I don’t know the demographics of your practice, but getting stirred up by mass shootings, understandable as it is, implies you are desensitized to the background. The real epidemic of gun-related deaths which, like swimming pools mentioned previously, are a smoldering epidemic. If reported faithfully they would drown out the numbers from mass shootings. And a very disproportionate number are African American men.
Last weekend’s episode of On the Media (which I like very much and has a liberal bias) gave a very balanced view of several issues which has made me re-think a few things.
I do not believe that gun violence can reasonably be considered a public health crisis. If your patient confesses to you that they have a gun what then. Ask if they can safely operate it? Ask if they are mad at anyone? Ask if they are mentally unstable? Convince them to agree with you that guns should be banned and they should give up their right to have one.
please
You are somewhat correct Barry – gun violence is only one aspect of several great public health crises (as mentioned above) – including climate change, the water crisis, obesity, food insecurity, loss of biodiversity etc etc. I think the question of the OP is what are coherent reasonable responses to the public health spectrum of concerns when an individual patient presents to us? Do we simply avoid mentioning smoking, pools, guns, speeding, domestic violence? Reductio ad absurdum arguments can be used to justify nihilism – but not to responsibly discharge our obligations to our patients, our communities and our planet.