June 22nd, 2016
Gun Violence — A Public Health Crisis
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: