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Do Doctors Know What To Say To Patients About Guns? Not If You Believe That Guns Aren’t A Health Risk.

January 26, 2016

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Since the health care industry now racks up revenues in excess of $1.6 trillion each year, there are plenty of online publications and other venues which are used to promote (i.e., advertise) the services and products driving this economic juggernaut.  And one such venture, an online publication called MD Magazine, caught my eye because it published a survey of subscriber attitudes towards guns and counseling patients about guns – a hot-button topic in the medical profession ever since Florida passed a gag order prohibiting doctors to talk to patients about guns.

conference-program-pic              While the Florida law didn’t absolutely prohibit doctor-patient gun discussions, it just relegated such discussions to situations in which the physician had reason to believe that the health of the patient was at imminent risk.  Of course since we are talking about behavior, it’s virtually impossible for a physician, or anyone else for that matter, to accurately predict imminent risk, which is precisely why doctors need the widest possible latitude in patient contacts, which is why doctor-patient relationships are circumscribed in every respect by the tightest degree of confidentiality, which is why the attempt to push the medical profession out of the discussion about guns is nothing more than pandering to the lowest, common intellectual denominator.  But what the hell, if you can build an entire Presidential campaign around your ‘love’ of the 2nd Amendment, why not demonize doctors into the bargain?

The good news about Docs-Glocks, however, is that it did result in the beginnings of a recognition on the part of physicians that they will only get back into the gun game if they bestir themselves and begin to argue for that role. Last April all the major medical associations issued a ‘Call To Acton,’ which not only endorsed the usual menu of gun-control options (background checks, assault-rifle ban, etc.,) but also made a commitment to be “part” of the solution to gun violence.  Which means that, like it or not, physicians must continue to advocate for the widest possible freedom in talking to patients about guns.

The problem with this more activist approach is that if physicians are going to engage in  unfettered, candid discussions with patients about guns, they have to know how to frame the discussions in ways that are both understandable and meaningful to their patients.  After all, the fact that the medical profession has decided that gun violence constitutes a serious medical issue does not, ipso facto, mean that doctors know how to explain the medical risks of gun ownership.  Knowing that guns are the instrument used in 31,000 fatalities and 70,000 injuries each year is one thing; knowing how to use that information medically is something else.

This is the context in which the survey in MD Magazine needs to be understood because the results indicate that many doctors do not currently engage in gun counseling, nor do they consider gun ownership a proper issue about which they should be concerned.  The survey, conducted online, was answered by 928 subscribers to the magazine.  When asked if doctors should “play a role in curbing in gun violence,” 43% said ‘no,’ 40% said ‘yes.’  When asked if they had ever asked patients about gun ownership, 60% said ‘no,’ and 40% said ‘yes.’ It also turned out that 60% of the survey responders claimed to be gun owners which is a rather remarkable statistic for physicians, assuming that this magazine’s readership is at all representative of the medical profession as a whole.

If nothing else, this survey reflects the fact that, until now, medicine has not developed a clear and coherent medical response to gun violence at the level where it is needed most; namely, in discussions between care-givers and patients, which is ultimately where all medical responses to any kind of medical risk needs to start and end.  The MD Magazine survey didn’t ask whether the survey respondents actually agreed that gun violence was a health issue.  Maybe the magazine’s subscribers practice medicine on Mars.

 

The 11th Circuit Creates A Fiction To Justify Gagging Florida Doctors Who Talk About Guns.

December 23, 2015

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Nobody in the GVP or medical communities (except Rand Paul) is happy with the decision by the 11th Circuit to continue upholding the Docs-Glock statute enacted in the Gunshine State.  But there was a comment in the latest decision which may, in the long run, make the argument in support of the law null and void. But before I explain why I think there may be a silver lining, I should spend a few words discussing where the case stands right now.

docs versus glocks              As you probably know, the original law was enacted in 2011 and similar statutes have been introduced but not voted in at least 12 other states.  Basically the law prohibits physicians from asking patients about gun ownership unless the physician believes that access to guns poses an immediate health risk. But by asking physicians to limit inquiries about any matter unless they have already decided that such inquiries might reveal a medical risk is to stand the entire methodology for assessing patient health on its head.

The pro-gun bunch has been trying to push medicine out of the gun debate ever since physicians first began talking about guns as risk to health.  The gun industry continues to pretend that we should ignore endless studies which show that gun ownership is linked to increases in both homicide and suicide rates; in fact, they promote the fiction that guns are a positive social element because it’s an armed citizenry that protects us from violence and crime.

Much of the latest decision upholding the Florida law simply repeats the rather dubious claims about 2nd Amendment rights that littered the original 11th Circuit majority decision handed down last year.  In that decision, the two-to-one majority hearing the case decided that asking a patient whether he or she owned a gun put the physician in the position of deciding whether that particular patient should have guns at all; hence, a restriction on the Constitutional right to own a gun.

This seems to me and to most scholars who have examined the decision to be a stretch.  And not just a little bit.  After all, Florida law doesn’t prohibit doctors from asking patients if they engage in sex, even though sexual activity is protected under the Constitutional rights to privacy that were enunciated in Roe versus Wade. But the reason that the doctor’s 1st Amendment right to ask any and all questions is trumped by the 2nd Amendment is really based on the fact that “the balance of power between doctor and patient will often make a patient feel as if he has no choice but to listen and answer a doctor’s questions.” Hence the 11th Circuit is protecting the patient who otherwise might feel vulnerable or threatened in asserting his 2nd Amendment rights.

Judge Gerald Tojflat (who wrote the majority decision) was fresh out of law school in 1963 when the Nobel prize-winning economist Kenneth Arrow published a paper in which he claimed that health care could not be understood as just another form of market economics because of the special relationship that existed between the seller (doctor) and purchaser (patient) of health products, procedures and advice.  Basically Arrow argued that patients could not exercise market decisions when choosing a doctor because of the physician’s superior knowledge and special skills.

That was 1963.  This is almost 2016. I don’t know which planet Judge Gerald Tjoflat inhabits, but he’s simply out of step with modern times. The idea that the average patient walks into a doctor’s office believing that he can’t or won’t speak up at every possible moment during a medical exam may have been typical of the doctor-patient relationship when Tjoflat was just starting his legal career, but it sure as hell isn’t true today.

Between the internet, alternative medicine, patient-centered care, patient’s bill of rights, and HIPAA, Judge Tjoflat’s notion that today’s patient feels vulnerable and helpless in relation to his physician is a relic of the distant past.  But he also probably believes that guns protect us from crime.

 

Docs Versus Glocks And The Docs Now Get A Helping Hand.

November 8, 2015

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Last week a California Congressman, Michael Honda, introduced a bill that, if enacted, would end what has been the nefarious and disturbing strategy adopted by the pro-gun gang to push medicine out of the gun violence debate.  This strategy has three basic dimensions: (1). To define the 100,000 mortalities/morbidities from guns as something other than a public health issue; (2). to prevent public health research into gun violence by defunding relevant research budgets of the CDC; (3). to criminalize and/or otherwise prevent physicians from talking to patients about access to guns.

Don’t think for a second that it’s only a bunch of yahoos and red-neck gun nuts who believe that 100,000 deaths and injuries committed with guns doesn’t constitute a problem for public health.  Last year we were treated to the spectacle of a U.S. Senator who happens to be a physician, if only a self-certified one, blocking the appointment of the Surgeon General because Vivek Murthy had actually stated that guns were a public health threat.  It should be added, incidentally, that this self-same jerk (not Murthy, obviously) claims that if he is elected President, he’ll uphold the “entire Bill of Rights, but specifically our right to bear arms.”  So I guess he’ll support the other nine Amendments but only in general terms.

docs versus glocks                The defunding of CDC research into gun violence was payback by the NRA for the Brady Bill and the ten-year assault weapons ban that were passed by Congress just before the Democrats lost their majorities in both the House and the Senate in the Republican landslide of 1994.  The spending cutoff didn’t end gun research per se, because private foundations and other sources jumped in and provided much-needed support.  But what the research ban accomplished was to send a signal to the medical community, both clinicians and researchers, that gun violence was simply not considered an issue of public concern.  Which made it that much more difficult to advance legislative responses to deaths and injuries from guns.

There are now three states which have passed laws copying more or less the Florida statute that criminalizes the behavior of doctors who talk to patients about guns.  This law, known as Docs Vs. Glocks, is still being kicked around in the Federal courts, but if it is ever declared completely and totally Constitutional, the law will no doubt appear in other gun-rich states as well.  The Florida law, of course, allows clinicians to talk to patients about guns if the physician decides that the patient represents a “clear danger” to himself or someone else.  Of course the only way that a physician can make such a determination about access to guns or access to any life-threatening situation is by having the widest possible latitude to discuss, in privacy, anything that goes on.  But try and explain this to the legislators in the Gunshine State who cynically cast a quick and easy vote reminding their constituents that protecting their 2nd-Amendment rights is more important than protecting their health.

Congressman Honda’s bill seeks to remedy this entire state of affairs.  Called the “Gun Violence Research Act, “ the bill specifically re-inserts language into the Public Health Service Act calling for research into ”the causes, mechanisms, prevention, diagnosis, and treatment of injuries, including with respect to gun violence;”  it also authorizes funding of this research through 2020; and most important, it prevents prohibiting a physician or other health provider from asking a patient about guns.

All the bill’s co-sponsors are Democrats, which shouldn’t surprise. But the good news is that we now have an explicit legislative remedy that can be used against the gun gang’s shabby and dangerous efforts to silence medicine about the health risks of guns.  Don’t get me wrong.  We accept many risks in everyday life and if someone wants to accept gun risk for whatever reason, they can do as they please.  But the role of the physician is to reduce harm, and guns are harmful, no matter what anyone says.

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Noth Carolina Joins The List Of Dumb States In Trying to Keep Doctors From Talking To Patients About Guns.

April 30, 2015

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Here we go again.  Another state legislature, in this case North Carolina, may be joining 3 other dumb states in enacting a law that will prevent physicians from talking to patients about guns.  The bill would prohibit physicians from mentioning guns on intake questionnaires and worse, prohibits physicians from telling authorities about concerns that arise from interviewing a patient about gun ownership.  This stupidity first began in Florida which passed such a law inaugurating a legal battle known as Docs Versus Glocks which eventually resulted in the law being upheld by the 11th Circuit in 2014.

The North Carolina law, however, goes further into the realm of stupidity because it not only enjoins physicians from asking patients about gun ownership unless the patient has expressed a desire to harm himself or others, but it also prohibits disclosing information about gun ownership to any authorities except in instances where the aforesaid patient – ready for this? – has been “adjudicated incompetent due to mental illness.”  Does this law actually forbid a physician from informing law enforcement about a potential act of gun violence because the patient in question hasn’t yet gone before a judge who decided that the guy happens to be crazy as hell?  That’s right.  That’s exactly what the bill which may be taken up by the House Appropriations Committee actually says.

docs versus glocks                This new law creates a rather interesting predicament for doctors even if they don’t feel compelled to ask their patients about guns.  Because let’s say that a patient tells a physician, for example, that he’s suffering from extreme depression and is thinking of taking his own life.  He then further tells the physician that he owns guns and he is planning to use one of the guns on himself because he knows that it’s the quickest and easiest way to get the job done.  Under this law, the physician can’t actually do or say anything at all.  The guy is depressed but he’s lucid and hardly mentally incompetent.  The doctor can ask the guy about what kind of gun he’s planning on using to blow a hole through his head, but all he can do is perhaps suggest that the patient rethink the whole idea.  He can’t even tell the patient to get rid of the gun because the law also says that an individual’s right to own a gun is a “private matter” over which the doctor has no authority or input at all.

I’m not totally surprised that such a law would be enacted when I consider the original source, namely a loony Republican State Representative named George Cleveland, who once stated that nobody in North Carolina suffered from ‘extreme poverty’ when, in fact, roughly 8% of the state’s residents have incomes that fall below the extreme poverty line, and overall North Carolina ranks as the 13th poorest state. This rock-red Republican, by the way, just happens to be a gun nut and you can get a sense of this from his home page on Pinterest which is covered with guns. Don’t get me wrong.  I don’t think that Representative Cleveland is a bad guy because he likes guns.  I think he’s a bad guy because this is a bad law.

Cleveland’s bill stands the Hippocratic Oath on its head. The law basically says that a physician cannot do or say anything to reduce the possible harm caused by someone who admits wanting to use a gun to hurt themselves or someone else.  Of course this same physician would be free to pick up the telephone and call the cops if someone walked into his clinic and said he was going to stab someone else with a knife.  If anyone other than the NRA really thinks this law is an important step forward in protecting our 2nd Amendment rights, then I just hope you’re not the guy or gal in North Carolina whose spouse just told a physician that they are going to grab you, grab their gun and put a bullet through your ear.

Want To Take A Public Health Approach To Gun Violence? Ask The NRA For Help.

March 29, 2015

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Here we go again.  Another state, Texas, is going to try and keep physicians from talking to patients about gun ownership thanks to a bill newly-filed by a state representative named Stuart Spitzer, who happens to be a general surgeon with a medical degree from UT-Southwestern Medical School.  The proposed bill goes further than the celebrated Docs vs. Glocks Florida statute which prohibits inquiry into gun ownership but makes an exception in cases where the physician believes that a serious medical problem might arise if the patient has access to a gun.  The Texas law contains no such provision, and simply says that any physician, other than a psychiatrist, cannot ask a patient to disclose firearm ownership, period. The end.

The bill’s sponsor peddles the standard nonsense about how this law will protect gun ownership because, according to him, the moment that such information is entered into a patient’s file, the Federal Government will be able to find out who has guns and who doesn’t.  This outright lie has been floating around the paranoid internet since Obama took office, even though the NRA has refuted it on their website.   But if Glenn Beck can find customers to stock up on freeze-dried food for the coming apocalypse, how hard is it for a Texas legislator to make others believe that Big Brother is waiting to grab their guns after a visit to their local doctor?

docs versus glocks                Even though studies show that most patients really don’t care if their doctor asks them about guns, people are sometimes susceptible to this blatant attempt at fear-mongering because they simply don’t understand the methods used by the public health community to define and treat medical risk.  It’s easy to get all worked up about Ebola because the danger is obvious; you don’t need to be a rocket scientist to figure out that with mortality rates above 50%, doing whatever is necessary to avoid this disease is a priority for government and citizens alike.  But is there a consensus on the medical risks posed by guns?  In a funny way there is such a consensus, but it’s based on the idea that guns don’t pose any medical risk at ball.

At the same time that public health researchers argue that the risks of guns outweighs the benefits, the NRA pushes the opposite point of view.  And while research clearly supports the public health position on gun risk, the NRA continues to use a bogus telephone survey by Gary Kleck and some thoroughly-discredited statistical nonsense from John Lott to sell the idea that guns are essential tools  in protecting us from crime. Using the fear of crime as a justification for guns is a master stroke of marketing because a majority of Americans now agree with the pro-gun point of view.

Know why the NRA and its allies have been so successful selling the positive utility of guns?  Because they have adopted a public health strategy for convincing the public and the lawmakers that what they are saying is true. First, identify the disease, which in this case is harm caused by crime.  Then identify how the disease is spread, in this case contact with a criminal.  Now develop a vaccine, i.e., the gun, and immunize as many as people as possible with concealed carry, now legal in all 50 states.

The problem in trying to sell the public health solution to any medical problem, as David Hemenway reminds us, is that unlike medicine, “the focus of public health is not on cure, but on prevention.” This usually requires a long, comprehensive strategy combining research, education and laws. Recognizing that most people aren’t usually responsive to solutions which don’t immediately work, the NRA has fast-tracked the process. The real problem in the gun debate is that the side which is totally resistant to an honest, public health approach to guns has shown itself remarkably adept at turning that same approach on its head and getting exactly what it wants.

 

Can Gun Owners And Non-Gun Owners Agree? I’m Not So Sure.

December 4, 2014

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Last week I wrote a column about a report on a Fox affiliate station in York, PA that presented a very balanced view on whether physicians should talk to patients about guns. What was interesting was the fact that a television station covering what is a very politically-conservative, gun-rich region would actually run a story which seemed, on balance, to promote the idea that doctors should be able to inquire guns.  Given the lengths to which the NRA has gone to muzzle doctors who want to discuss this issue with patients, I found it surprising that a somewhat “pro-doc” slant would come from Fox News.

docs versus glocks                I wasn’t the only one who found it interesting because this post made it all over the web and was featured on sites owned by gun partisans on the Right and anti-gun partisans on the Left.  I thought it would be instructive to look at these sites in a little more detail to get a flavor for how the average person, gun owner and non-gun owner, lined up on what has been a highly-contentious issue.  And what I discovered didn’t leave me with any warm and fuzzies in terms of the degree to which either side in the gun debate understands what the other side is talking about.

Let’s look at the pro-gun side first, in this case a blog published by MN (for Minnesota) Gun Talk.  The conversation began with a link to the story out of York, PA as replayed on Yahoo News.  This was followed by 40 posts, but as is usual in such blogs, the majority written by just a couple of folks. And it goes without saying that even though the original story quoted two doctors as stating that they were asking about guns solely in terms of preventing gun accidents, none of the gun owners on this blog took the doctors at their word.  For that matter it’s not clear that any of the bloggers even bothered to watch the clip from Yahoo News.  For the most part they were too busy throwing the usual dumb comments and dumber profanity back and forth between themselves.

The other side of the gun fence was a website devoted to baby care, birthing and a host of other very compassionate issues which ran a story about Florida’s gag law in which the blogger was critical of any attempt to prevent physicians from talking to patients about guns. The story was followed by a reader’s poll in which readers who felt that pediatricians had the right to inquire about guns outnumbered readers who were against such inquiries by a ratio of six to one. Of the 185 comments that followed the story, they were overwhelmingly posted by readers who felt that their pediatrician was behaving properly in asking about guns, and a significant number of bloggers on this site admitted that they didn’t and wouldn’t own guns at all.

I find these websites much more revealing about the average person’s thoughts on gun issues than the pronouncements that come down from the formal, advocacy groups on both sides.  Not that the views of the NRA are contrary to what their membership believes, nor would Brady or Everytown take a policy position that wouldn’t be favored by the supporters of those groups.  But what you get from these blogs and websites is what individuals at the street-level are thinking, not what a professional media or communications staff feels will promote their agenda and point of view.

There’s only one little problem.  I read all 40 posts on the pro-gun blog and nearly all of the 185 posts on the baby center site and I must say that the tone and content of the two threads were about as far away from each other as what I get when I look at content from Brady or the NRA.  People who like guns are willing to accept and/or deny certain risks, and people who don’t like guns won’t accept those risks.  And you’re not going to close this gap by pretending that there’s a way to make guns “safe.” That’s not what guns are designed to do.

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The Virus Is Spreading And I’m Not Talking About Ebola

October 16, 2014

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Last month the Missouri legislature passed a new gun law that was essentially a rewrite of a bill vetoed by Governor Jay Nixon.  Missouri has been in the forefront of easing restrictions on gun ownership and this law continues that trend.  In 2007 a decades-old law that required state residents to apply for police permits to purchase handguns was overturned, and the result was an immediate spike in gun homicides.  The new law drops the minimum age for concealed-carry from 21 to 19, allows teachers to bring concealed weapons into schools, and prohibits towns, counties or other local jurisdictions from promulgating gun laws that conflict in any way with state statutes.

According to the law’s sponsor, Republican Senator Will Kraus, the law was designed to protect the rights of gun owners who had “earned” concealed-carry privileges by dint of voting or military service.  Could this guy have a statement that dumb on the floor of the State Senate?  Obviously he did, and he went on to say that a concealed-carry license also gives state residents the right to carry a weapon openly, again because they had “earned’ this right by dint of registering to vote.

docs versus glocks                If the Missouri State Legislature wants to make it easier for state residents to pretend they can keep everyone safe by walking around with a gun, I really don’t care.  Despite the continued mouthings of John Lott and other NRA sycophants, there is simply no credible evidence which proves that legal gun ownership reduces crime.  The good news about concealed-carry is that most people who have a CCW permit actually don’t bother to walk around with a gun, and while CCW on the one hand doesn’t lead to less crime, it also doesn’t seem to spark any great increase in crime on the other.

But what I am concerned about is another part of the law which makes Missouri the second state to gag physicians who try to ask patients about their ownership of guns.  Here’s what the law says: “No health care professional shall be required by law to inquire whether a patient owns or has access to a firearm.”  It then goes on to prohibit physicians from noting gun ownership in a patient  records or disclosing the identity of a gun owner to “any government entity” unless the physician is ordered to disclose such information via court order, blah, blah, blah. The final clause of this section of the law contains the usual bromide about how gun ownership can be discussed if, in the physician’s professional judgement, the patient’s access to a gun might be of medical concern.  But make no mistake about it: Missouri, like Florida, has now instituted a gag order against physicians talking to patients about guns.

What really concerns me about this attack on physicians is not the fact that it has taken place.  Frankly, once those two idiots on the 11th Federal Circuit upheld the Florida law, I assumed that it would be replicated in state after state.  The bigger problem is that I learned about Missouri closing down physician inquiry from reading the text of the Missouri law itself.  When the Florida law was first passed, the Brady Campaign, the American Academy of Pediatrics and a host of other medical groups not only went immediately to court, but kept up a steady drumbeat about the issue and even now are asking that the 11th Circuit’s bizarre decision be overturned.  In the case of Missouri, nobody seems to have noticed that the gag-MD virus has spread.

The real reason that the gunnies want to push physicians out of the discussion about gun violence is not because physicians are opposed to guns.  It’s because the NRA and its allies want to disconnect gun ownership from violence to make their products more acceptable, more enjoyable, more normal for every dad and mom.  After all, we agree that violence is abnormal but guns don’t pose any threat at all.  Isn’t that right, doc?

 

Docs Versus Glocks: Now It’s Round Four.

September 6, 2014

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Last month a three-judge panel of the 11th Federal Circuit reinstated Florida’s gag law that prevented physicians from talking to patients about guns, a law that had been initially struck down at the Circuit Court level in 2011. Now the physicians have asked for an en banc rehearing of that decision by the entire 11th Circuit which, if the panel decision is affirmed, may move this case one step closer to a hearing before the Supreme Court.

The plaintiff’s brief, whose amici reads like a Who’s Who of virtually every medical association beginning with the AMA, notes that “there is no disagreement within the medical community that providing patients with information about firearm safety is a valid aspect of preventive care and thus beneficial to public health.”  They contend that the state’s gag order not only prevents physicians from delivering proper medical care, but opens the door for other limitations on physician-patient discussions because “once it is known that physician communications can be compromised in one area, then politically empowered interests will be emboldened to compromise it in others.”  Florida’s legislature, for example, could use a similar justification to limit whether a physician can ask a patient about whether they smoke cigarettes, drink alcohol or consume red meat.

glock logo                The gun lobby’s answer to this problem, which was echoed by the panel decision majority, was that physicians are always free to hand out gun safety pamphlets which, of course, the NRA is always happy to provide.  But the NRA’s support of gun safety information is disingenuous at best and consciously deceptive at worst, because this same organization is on record as opposing laws that would really increase gun safety by requiring that guns either be locked or locked away.  Arizona was the 50th and last state to legislate protective barriers around backyard pools in homes where minor children live.  Want to guess why there are still 22 states that do not mandate any kind of safe storage of guns at all?  Last year in Kentucky a five-year old boy shot and killed his two-year old sister and the County Judge drily observed that “there’s probably not a household in this county without a gun.”

I’m not surprised nor really upset that the gun lobby would try to keep physicians from talking to patients about guns.  After all, if the medical associations are on record as believing that gun ownership is a health risk, then they will line up some way or another as being against guns.  And the fact is that physicians have reams of peer-reviewed studies that link higher levels of gun mortality and morbidity to ownership of guns.  Even without the studies, you don’t have to be a rocket scientist to figure out that the more guns there are in everyone’s homes, the greater are the odds that more of them will be left around unlocked, and as the novelist Walter Mosley says, “If you carry a gun, it’s bound to go off sooner or later.”

But even though virtually every medical association acknowledges that guns constitute a risk to health, somehow this message still hasn’t gotten back to the feds. In response to a call from President Obama after Sandy Hook, the Institute of Medicine published a report listing the major gun violence issues that needed further research over the next 3-5 years, including the influence of video games, interventions and strategies, risk and protective factors, safe guns and, most important, “characteristics of firearm violence.”

With all due respect, I would like someone to explain to me why we need more research on the characteristics of gun violence to understand why 100,000 deaths and injuries from guns each year constitutes a risk to health.  I don’t believe there would be such unanimity among the national medical societies on this issue if it were just because most doctors don’t like guns. But as long as the federal government can pretend that the ‘jury Is still out’ on the medical risks of gun violence, jurors like the panel majority of the 11th District can tell physicians not to talk to their patients about guns.

 

 

 

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