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How should doctors talk to their patients about the risks of owning a gun?

Research suggests that doctors are nervous and feel ill-equipped to counsel patients about gun ownership
August 3, 2017 | Comments

In February of this year, a federal appeals court in Florida struck down a law that was a favorite of the National Rifle Association (NRA). The law restricted what healthcare providers could say to patients about gun ownership. The law was known as the Privacy of Firearm Owners act and the court ruled that it violated the First Amendment rights of doctors.

The NRA has been speaking out in  this legal battle since it began. In a letter about the case in 2015, the NRA’s Institute for Legislative Action wrote “Physicians interrogating and lecturing parents and children about guns is not about gun safety…It is a political agenda to ban guns. Parents do not take their children to physicians for a political lecture against the ownership of firearms, they go there for medical care.”

As usual, the NRA has focused exclusively on questions of political freedom and individual rights when the real issue is health and safety risk. What the NRA refuses to acknowledge, again as usual, is that most Americans buy guns in order to avoid a situations they view as extremely risky, like having their home broken into by an armed intruder. Americans keep guns in their homes for the most part to “protect” their families, or at least that is the reason most people state in national surveys such as Pew polls. In reality, as abundant data have shown, having a gun in the home puts families at risk. At the same time, the risk of being injured or killed by an armed intruder is actually miniscule in comparison. The moment a gun is introduced into the home, the risks of someone in that home being killed by that very gun, whether by tragic accident, homicide, or through suicide, increases significantly.

The choice to buy a gun to protect one’s family from armed intruders or other assailants is a choice governed by a wide array of common psychological miscalculations, including a serious misperception of risk. There are obvious and understandable emotional and psychological reasons why no one wants to believe that the risk of someone in their family attempting suicide could be anything more than remote or non-existent. We discuss these reasons at length in Denying to the Grave.

Given the “irrationality” of the decision to own a gun and the psychological resistance to facing the real risks associated with having a gun in the home, coupled with the serious and persistent public health challenges posed by gun ownership in this country, how should physicians and other healthcare providers talk to patients about guns?

Physicians are some of the most trusted authorities in this country, and they certainly have a role to play in minimizing the serious health risks posed by guns. So why do so few physicians typically address these issues with their patients? How can we get more health care providers to discuss this risk with their patients? And what techniques actually work to persuade people that owning a gun might not be as harmless as they think it is?

Existing Guidance

Before we get into the reasons why doctors often fail to discuss gun ownership with patients, let’s review the current guidance on these conversations. The American Academy of Pediatrics has a few guidelines on how pediatricians should discuss firearm-related risks to children’s health. Overall, the guidelines recommend asking patients about the presence of firearms and about storage habits, especially if there is reason to suspect potential for domestic violence and/or suicide. The guidelines recommend that physicians discuss removal of guns with family members of any pediatric patient who seems depressed or suicidal. The AAP also recommends that all pediatricians routinely screen adolescents for mental health disorders and substance abuse.

The American Psychiatric Association has issued guidelines along similar lines. In this document, the APA lays out the heightened risk for suicide when lethal means are readily available. The guidelines recommend that psychiatrists ask all patients whose risk of suicide appears high about access to firearms.

These guidance documents are certainly an important step in the right direction. They all acknowledge that gun ownership poses serious threats to public health and personal safety, and they all recommend that the physician gain an accurate understanding of high risk patients’ access to firearms. The problem is that very few physicians, even psychiatrists who deal regularly with suicidal patients, actually follow this guidance and inquire about gun ownership. Furthermore, these guidelines do not give physicians many ideas about what to do once they determine that a high-risk patient does in fact have access to a gun. Should the physician demand that the patient get rid of the gun? Should he or she call the patient’s family and get them involved in this serious threat to the patient’s safety? Should they ask the patient seemingly invasive questions about why they own a gun? Or should they simply recite statistics about the threats associated with gun ownership and hope that patients will listen? Clearly, there are still a lot of open questions when it comes to this sensitive and sometimes politically-charged topic.

What Holds Doctors Back

Even when healthcare providers have some sense that they should be asking patients about gun ownership and explaining the associated risks, it turns out that many of them choose not to broach the topic. Why is this? The answer lies in a complex combination of lack of confidence in their ability to effectively counsel on the topic and a feeling that patients will not take kindly to their advice on the matter.

Although there are again not nearly enough studies on barriers that physicians perceive to counseling on gun safety, there are a few interesting findings that should guide our approach to this topic. A handful of studies have found that psychiatrists often feel that they lack expertise in this area, that they can’t really accurately assess suicide risk in most cases, and that they aren’t trained to advise patients on gun safety measures. In addition, many psychiatrists also claim that they don’t counsel on gun safety because patients don’t usually broach the subject in the first place. Family practice physicians have similar reasons for not counseling patients on gun safety: they tend to cite lack of time, lack of expertise, and a sense that patients would ignore their advice as reasons for not engaging in conversations about gun ownership and associated risks with patients.

Some healthcare professionals seem to get defensive when asked about this subject. In one study, an overwhelming number of psychologists claimed that the reason they don’t ask patients about gun ownership is because they don’t think their patients need counseling in this arena. This seems like a bit of a weak defense – although it is true that it can be difficult or impossible for mental health care professionals to accurately predict someone’s suicide risk, it is certainly the case that anyone who seems like they might be at high risk of suicidal behavior should not be left alone with a gun. Most psychologists and psychiatrists do know this, so claiming that there’s no need to broach the topic seems a poor excuse.

While a prevailing sense of lack of expertise and that gun owners won’t listen to their advice seems to drive health care professionals away from discussing gun ownership with their patients, it is definitely the case that high perceived self-efficacy in this arena does result in more counseling on gun safety. That is, if health care professionals are reluctant to discuss gun ownership with their patients because of an overwhelming sense of hopelessness about their ability to make a difference in this area, it’s also equally the case that boosting health care professionals’ confidence results in more counseling on gun safety. This is important because it indicates first of all that the decision to refrain from counseling patients is probably not entirely “rational” but actually contains a strong emotional component on the part of the doctor and furthermore it demonstrates that part of the answer to the problem has to be showing doctors that discussing gun safety with patients does make a difference.

That means that rather than communicating statistics about how harmful guns are to human health (most health care professionals already know these statistics anyway), perhaps we should be focusing our efforts on showing doctors and other healthcare professionals how gun safety counseling has made a tangible difference in patients’ lives. This approach would obviously need to be rigorously tested, but it’s worth noting that telling success stories tends not to be our first choice in situations such as this, and we may be doing ourselves a terrible disservice by focusing so many of our communications on the problem rather than on the solution.

Beyond finding ways of improving doctors’ perceptions of their own ability to successfully provide this kind of counseling, we need to establish a much stronger evidence base about what works and what doesn’t work in this area. Subtle changes in communication can make a big difference. For instance, there’s some evidence to suggest that giving people pamphlets doesn’t do much to change their attitudes but that engaging them in some form of online, interactive communication might. Far more research is needed to understand what kinds of communication in what formats work best for this particular topic.

Gun ownership is not  easy topic to broach for anyone – it involves not only a personal preference but also constitutes a form of identity. Gun owners are often highly identified with the fact that they own guns – there are social networks of gun owners to reinforce this and political affiliations to cement the importance of this identity even more. Most people don’t own guns nonchalantly the way they own oven mitts or stamps. Owning a gun is often an important part of people’s identity and of the communities in which they live. It often represents a set of values and beliefs for many individuals and groups across the country. No wonder doctors are hesitant to discuss it, let alone suggest to people that they give up their guns. It’s understandably a daunting task. But in too many cases, gun ownership has tragic health and safety consequences, and therefore it is the doctor’s prerogative to intervene. But we need to provide doctors with much better, evidence-based tools to manage these difficult situations. It’s not enough to make them aware of the problem. We have to offer a viable and acceptable solution too. There’s too much at stake to do otherwise.

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