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Should Doctors Talk to Patients About Guns?

September 19, 2023

mikethegunguy Blogs , , 2 Comments

Dear Readers:

              Let me warn you that today’s column is longer than my usual 600-700 words. So, I hope you will set aside a bit of time to read the entire thing and spend a moment reflecting on what it says.

              Before I get into the specifics, I want to say that on at least two occasions, I had the great fortune to be able to talk candidly and completely with skilled and responsive physicians about disquieting medical symptoms which were affecting me and one of my kids. I couldn’t have gotten this kind of advice and foreknowledge from anyone else, and I will never (read: never) join with any of those shitheads, including a former President, who rant and rave about the ‘fraud’ of modern medicine or how immunizations should all be banned.

              However, I also believe that if doctors are going to deliver remedies to medical risks, then they need to understand what those risks really involve, and in the case of gun risk, doctors don’t know enough about guns to promote themselves as the professionals whose beliefs and treatments should be accepted in that regard.

              I refer to an article which just appeared in a medical journal, “Firearm Screening and Counseling in General Medicine Primary Care Clinics at an Academic Medical Center” and can be downloaded here.  The article’s authors asked 109 medical providers in 10 Michigan clinic sites to answer questions about counseling patients on gun risk and found “a generalized resistance from patients and providers alike to discuss firearm safety,” which is similar to other, similar studies on gun counseling conducted over the past years.

              For guidance in creating this survey, these researchers cite an article published by one of the gurus of gun violence prevention, Garen Wintemute, along with several other alleged gun  violence experts, an article which has become the non plus ultra resource for helping doctors learn how to talk about guns, and you can download that article here.

              How do Wintemute and his colleagues advise physicians to counsel patients about guns? First, they present an ‘epidemiology’ of gun risk, which is totally based on the demographics of people who are shot with guns. Now I’m not an M.D., I’m only a lowly Ph.D., but I always thought that epidemiology is a method which is used to help determine how a threat to health moves from one victim to another, which when it comes to gun violence, you won’t get even the slightest hint if your data only covers information about the people who get shot.

              The WHO defines violence as any conscious attempt to injure yourself or someone else. But when it comes to gun violence, less than 20% of all shootings involve the victim also being the person who shoots the gun. So, if you do research on gun violence and only look at the demographic profile of people who get shot with guns, you happen to be missing at least 80% of all gun violence events.

              The Wintemute group then goes on to tell us about why people own guns, the idea being that if you are going to counsel gun owners about gun risk, you need to deal with their interests, concerns and fears which made them go out and buy a gun. And what data is used to figure this problem out? The same data which has been used in virtually every research done on guns over the past twenty years that shows a majority of gun owners buy a gun in order to protect themselves.

              The next sentence is the single, most important sentence in this entire column, so please read it slowly, perhaps read it several times and spend a few moments thinking about what the sentence says, okay?

              There has never been one, single study produced by public health, physicians or medical caregivers about guns which asks gun owners to describe the type of gun which they own. Not one. Not one, single study.

              And unless you know what kind of gun(s) you are talking about, getting into a discussion with a patient about gun risk is a total and complete waste of time. Because even though all guns represent some degree of health risk once they are loaded with ammunition that really works, the difference in lethality of different kinds of guns can be extreme.

              You don’t buy a Glock 17 with a hi-cap magazine which holds 16 rounds of tactical ammunition (the word ‘tactical’ is a polite way of saying that someone might get killed) to knock a birdie out of the tree. You also don’t buy a 22-caliber, bolt action, single-shot rifle to walk around the neighborhood carrying a gun.

              Gun owners are very sensitive to this issue and love to walk into a gun shop and talk on and on with anyone else in the shop about the design and use of different kinds of guns. I know this because I have sold guns to somewhere around ten-thousand-gun owners in the gun shops I have operated in three states.

              Physicians admit in survey after survey that their reluctance to counsel patients on gun violence often stems from their lack of knowledge about different types of guns. Does Wintemute’s article or the study out of Michigan even raise this point or God forbid advise doctors to spend some time learning about the different types of guns? Of course not.

              There must be a couple of hundred books on gun design listed on Amazon. There are also YouTube videos, including this very informative, hour-long video by a clever, young man which could easily be converted into a one-credit CME online course, if one of the so-called medical gun experts would even mention anything about why doctors should learn at least a few specifics about the guns which create the risk about which they are so concerned.

              And what is the remedy for gun violence that these medical and public health experts promote clinicians to advance? Store those guns safely – that will do the trick. Now the fact that there has never been one, single study showing any change in gun violence rates after a control group of patients reports they are paying more attention to gun safety than before, big deal, right?

              Probably the most detailed study of how and why Americans own guns was published by the Harvard gun-research group in 2015. You can download that article right here. This piece goes into great detail about how many Americans own guns, what kinds of guns do they own, when was the last time they purchased a gun and when was the last time they sold or gave one of their guns to someone else.

              This article made all kinds of noise in the media because it identified a group of ‘super owners,’ representing just three percent of the adult population who together own half the country’s guns, for an average of 17 guns apiece.

              There was only one little problem with this article, a problem which basically renders the research totally meaningless for understanding or counseling on the risk of guns. Men and women who are legal gun owners by and large rarely commit violence of any kind with their guns. Maybe once in a great while some gun owner and his wife get into a brawl, and he decides to finally get the old lady out of his hair by popping her with a gun.

              But the reality of guns as representing a threat to health happens to be when someone who is unable to legally own a gun gets their hands on a gun. Who are these individuals and what kinds of questions do they need to be asked in order to determine whether they represent any degree of gun risk? You won’t find one, single word about this problem in any published research from the medical community which allegedly explains to clinicians how they should talk to patients about guns.

              Last point. I don’t see in any of the advisories about how health professionals should discuss gun risk any mention simply to get rid of the guns. Which, by the way, happens to be the one, guaranteed strategy that will reduce gun violence.

              Oh, I forgot.  My bad. Americans have a Constitutional ‘right’ to own guns. Know what? Article 1, Section 8, Clause 3 of the Constitution also gives Americans the ‘right’ to buy and smoke cigarettes. It’s called the ‘commerce clause.’

              So how come physicians have no trouble telling their patients who smoke to get rid of the cigarettes?

Should physicians talk to their patients about guns? Maybe they should first take the trouble to learn something about what they want to say.

Do Physicians Understand a Health Risk Called Gun Violence?

July 24, 2023

mikethegunguy Blogs 5 Comments

              I love how the media refers to the ‘epidemic’ of gun violence in the United States, as if an epidemic can last for 30 or more years. What we have in this country is an endemic gun violence problem, which produces more than 100,000 deaths and serious injuries year after year.

              And why do we experience this endemic gun violence problem, when we have solved epidemics like Covid-19 in jut several years?

              We have the problem for two reasons, and we will continue to have it until these two reasons change.

Reason #1: The United States is the only country in the entire world which allows residents to buy and own guns designed and manufactured only for the purpose of killing human beings. For every person who is killed by one of these guns, two other individuals suffer serious but are not fatally injured because the shooter didn’t properly aim the gun.

              Semi-automatic, bottom-loading pistols from companies like Glock, Sig, S&W, Ruger, et. al., are referred to as ‘self-defense’ guns. But they happen to be used offensively most of the time, and because a million or more of these guns are added to the civilian arsenal every year, some of them wind up in what we refer to as the ‘wrong hands.’

Despite the fact that Detroit now puts all kinds of anti-theft devices on cars, more than a million vehicles are stolen every year. So how can we prevent a few thousand guns from being swiped and resold in the street? We can’t.

When I looked at the more than 9,000 guns picked up by cops in 2014, what struck me was how many of these guns were at least thirty years old. Guns don’t wear out, okay? Once a gun gets into the criminal market, it stays there and will be used again and again.

So, either we get rid of the guns whose use causes gun violence, or the violence will continue every day.

Reason #2: The profession – medicine – whose research and practice we depend on both to explain threats to public health as well as to develop practical measures for dealing with such threats, now promotes a response to the gun violence problem which doesn’t reflect the problem at all, and worse, ignores the findings of evidence-based research.

It is thirty years since Art Kellerman and Fred Rivara published definitive research clearly demonstrating that access to guns in the home creates medical risk. The authors of these studies did not qualify access in terms of how guns were used, owned, or stored. They simply found that guns and gun violence are one and the same thing.

Now we have a new initiative from one of America’s most prestigious medical institutions, Massachusetts General Hospital, a training program for first-year medical residents which teaches these new physicians how to talk to patients about guns and gun violence in clinical settings, the idea being that this training will overcome the natural reluctance of physicians to engage in conversations with gun-owning patients about the risk of guns.

The training sessions focus on talking about gun risk in a non-judgmental manner to gun-owning patients, followed by a discussion about making guns ‘safe’ and offering gun locks as well as discussing legal measures like extreme-risk prevention orders (ERPO) to remove guns from individuals whose behavior clearly marks them as potentially using a gun in a violent way.

The curriculum developed for this effort is designed to impart basic ideas about gun ‘safety’ with the word ‘safety’ appearing countless times in the text. Which only shows how this curriculum was developed by a well-intentioned group of physicians who don’t know anything about guns.

Leaving aside the fact that there has never been a single study showing any connection between educating gun owners on gun risk and a consequent change in gun violence rates, the idea that one can talk about a handgun loaded with 16 rounds of military-certified ammunition in terms of being a ‘safe’ gun is absurd.

Worse, and this is where the medical approach on gun violence borders on the criminal, if not on the absolute senselessness of their ideas, is that one can develop mitigating mechanisms to thwart gun violence without getting rid of the guns.

And why do physicians like the Massachusetts General group create an entire educational program on gun violence which in not a single sentence anywhere in the curriculum state that the preferred goal should be to eliminate access to the kinds of guns which are only used to inflict serious harm?

Because these doctors and their colleagues in other medical institutions actually base their curricular model on the idea that maybe they can find some common ground with gun owners and thus not be seen as being anti-gun.

This may come as a great shock to the medical professionals who continue to lament the human carnage caused by guns every day, but the 2nd Amendment actually gives government the authority to determine which kinds of guns can be owned by law-abiding adults and which kinds of guns cannot be owned.

Don’t believe me? You’ll find the relevant text on pp. 54-55 of the Heller decision which is precedent for what today’s interpretation of what the 2nd Amendment actually means.

I’m not asking doctors to become legal experts. I’m also not expecting them to meet me at a shooting range and spend the day learning about guns. But I do expect them to stop trying to fashion some kind of educational program about gun violence based on some nonsense about the values and virtues of ‘safe’ guns.

That’s simply crap.

The American Medical Association Needs To Be Clear: Guns Are A Risk To Health.

May 31, 2018

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Our friends at The Trace emailed an article yesterday about the decision by the American Medical Association to debate and possibly adopt some gun-control measures when the organization gets together for tor their annual meeting in June. According to the AMA President, David O. Barbe, a family physician out of Missouri, the grand poo bah of all grand medical organization poo bahs will debate a nearly a dozen proposals to reduce gun violence and then put its “considerable lobbying clout behind legislation heading into November’s mid-term elections.”

md-counsel             The AMA is already on record backing such ‘commonsense’ strategies as comprehensive background checks, handgun licensing and waiting periods and ‘mandated penalties’ for gun crimes, whatever ‘mandated’ means. According to Doctor Barbie, this year’s grab-bag of proposals includes banning bump stocks, strengthening the background check system, banning assault rifles and high-cap magazines, and increasing the legal age for gun purchases from 18 to 21. All of these ideas and others stem from a basic notion, says Dr. Barbie, that “gun violence in America today is a public health crisis, one that requires a comprehensive and far-reaching solution.”

I am going to be rather blunt and somewhat descriptive by saying that I think Dr. Barbie and his AMA colleagues are once again reducing the issue of gun violence to just another talking-point which, if debated and adopted at the annual meeting, will accomplish absolutely nothing at all. In other words, it’s a load of crap. God knows we have enough decent, dedicated and devoted gun-control advocates and organizations promoting these same issues all the time. Why should the medical profession, which represents the most objective and science-based approach to how their responsibilities and practices are defined, just get on line behind everyone else who wants to do something about the 125,000 deaths and injuries suffered each year because of guns? What the AMA should be doing is insisting that the issue of gun violence be taken seriously within the practice of medicine itself.

Every medical school curriculum contains teaching modules about violence – how to define it, how to spot it, how to counsel about it and who needs to be contacted if the patient is at immediate risk. Guess what?  You can search all these treatment protocols and you won’t see the word ‘gun’ or the term ‘gun violence’ even once. And gun violence isn’t the same thing as picking up a baseball bat and whacking your younger bother over the head. It’s not the same thing as getting into a fight. It’s a random and highly lethal type of behavior that creates a level of injury which at best requires a significant outlay of medical resources and at worst leaves the victim dead.

What do we get from the medical profession these days when it comes to discussions about what to tell a patient who says that he or she has access to a gun?  We get this nonsensical and ill-advised bromide about safe storage because, after all, we need to ‘understand’ and ‘appreciate’ the culture of patients who believe they are safe if they own a gun.

The studies which show that guns are a risk to safety and health do not distinguish between stored and unstored guns. And as far as I’m concerned, a physician who does not advise patients to get rid of their guns, pari passu, is teetering on the brink of violating the Hippocratic Oath, which does not (read: not) make exceptions for patient ‘culture’ as regards the doctor’s responsibility to reduce harm. Doctors should join and lead the gun-violence discussion by talking about what they know, which is the issue of medical risk. And medical organizations like the AMA should be promoting one very clear message, namely, that guns are a risk to health. This means all guns, no matter how they are stored or how many background checks are required before owning a gun. I know this, and even though I’m also a doctor, I’m just a lowly Ph.D.

 

Another State Wants At-Risk Gun Owners To Protect Themselves From Their Guns.

April 17, 2017

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Last week I wrote about a bill in the Oregon legislature that would allow family members to petition a court for removal of guns in cases where a gun owner was an immediate risk to himself or someone else.  The bill, known as a measure to be used only in instances of ‘extreme risk,’ would require the gun owner to surrender his firearms for up to one year, but the gun owner could also appear in court and present evidence that his access to guns no longer represented a risk to himself or anyone else.

gun-suicide             The Oregon initiative follows the adoption of a similar law in California, which allows family members to ask for a restraining order on access to guns. But this week the virus seems to be spreading to the other coast, because a similar measure has just been introduced in the Massachusetts House, and it appears to have enough sponsors to be taken seriously when and if the Massachusetts legislature stops arguing over the annual budget.

I learned about the Massachusetts law because of an email I received from my friends at the NRA, which linked to a statement about the law by the NRA-ILA.  According to America’s oldest civil rights organization, the Massachusetts law, if enacted, would “result in the immediate suspension and surrender of any license to carry firearms and firearms identification card which the respondent may hold.  The respondent would also be required to surrender all firearms and ammunition.” The NRA then goes on to repeat the usual canard about how such an order would be issued based on ‘little, if any real evidence,’ but that’s simply not true.

But the best part of the NRA’s attempt to explain Constitutional law to its membership is the sentence which reads: “Constitutional rights are generally restricted only upon conviction of a felony.”  Did the legal geniuses at Fairfax ever hear of something called ‘prior restraint?’ The rights enumerated in the Constitution are all subject to ‘reasonable’ restrictions imposed by governmental authority, as long as those restrictions meet basic tests regarding the intent and result of what government intends to do. Such restrictions are even explicitly stated in the landmark Heller decision, which states that “Like most rights, the right secured by the Second Amendment is not unlimited, and “nothing in our opinion should be taken to cast doubt on longstanding prohibitions on the possession of firearms by felons and the mentally ill.”

Which is exactly what these ‘extreme risk’ laws are designed to do, namely, keep guns out of the hands of individuals who have shown a disregard for the traditional rules of behavior under which we all live. Sorry, but telling someone that you are depressed to the point of wanting to commit suicide isn’t just an idle threat. Ditto stalking or threatening someone who told you to leave them alone. The Constitution doesn’t enshrine such behavior and such behavior becomes a much greater threat when it might involve a gun.

But remember who we are dealing with here, namely, an organization which increasingly promotes the idea that there should be no restrictions of any kind on the ownership or use of guns. Believe it or not, I would have no problem with the NRA or any other pro-gun advocacy group if they would just drop the nonsense about how guns aren’t really dangerous because we can use them to protect us from crime.  If the NRA would admit the truth, namely, that guns are extremely lethal and that access to a gun increases risk, I would fold up this website immediately, stick my guns, my wife and my cats in the Subaru and take off to a trailer park in the Florida Keys.

The fact that something is dangerous doesn’t mean it shouldn’t be owned. I know a guy who keeps rattlesnakes but treats them with extreme caution and care.  Are we asking too much of my gun-owning friends to behave the same way with their guns?

How Do You Convince People That Guns Are A Risk? Maybe By Not Talking About Guns.

March 21, 2016

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conference program pic           In the face of more than 100,000 serious injuries and deaths every year, it’s pretty difficult to accept the idea that gun violence isn’t a public health issue, yet promoters and defenders of gun ownership continue to insist otherwise.  And while it would be easy to assume that such warped thinking is the product of infantile and/or uninformed minds, medical and public health communities have been spectacularly unsuccessful trying to convince Americans that guns constitute a risk to health.  In fact, both Gallup and Pew polls indicate that a majority think that guns protect us from crime, even while the same majority also support expanded background checks.

In light of the divergence between public health research findings on the one hand, and public opinion in the other, I am beginning to think that perhaps the problem lies not in the power and messaging of Gun Nation, but reflects the possibility that perhaps public health research should stop focusing so much energy on the public aspects of gun violence and spend more time thinking about the health aspects of the problem, in particular, the issue of why people own and use guns.

Because there would be no gun violence if a certain number of people each year didn’t misbehave with their guns.  And the issue of behavior is never far removed from the manner in which the medical profession deals with disease. The mortality numbers for serious illnesses would be much different if we changed behaviors like smoking, excess eating and drinking which cause heart disease and cancer which leads to medical distress.

The medical response to behavior which leads to gun morbidity, however, seems to largely put the cart before the horse. Doctors are being advised to counsel patients on safe gun storage, as if gun violence will be ‘cured’ by locking the guns up or locking them away.  I’m not against safe storage, but less than 4% of gun injuries occur because a child grabbed an unlocked, loaded gun.  The overwhelming amount of gun violence, for which the medical costs alone are estimated to be at least $50 billion each year, takes place because someone made the conscious decision to use their gun to injure either themselves or someone else.  And that decision is rarely going to bear on whether the gun is locked away.

Last year a public health research team conducted a survey of 4,000 adults of whom one-third reported owning guns.  Half of the gun-owning group also reported that they engaged in social activities involving guns with either family members or friends. Which meant that for these folks the ownership of guns goes far beyond believing that guns make them safe.

To people for whom gun ownership is how they create their social milieu, guns represent honesty, patriotism, family and other cultural artifacts which form a basis for self-expression and communication between family members and friends. So when such folks perceive a threat to their ownership of guns, this perception quickly becomes a threat to their self-identity as well.  Which means that trying to prove that guns are a risk will only push such individuals to harden their resistance against losing their guns.

“If individuals adopt one position or another because of what guns mean instead of what guns do, then empirical data are unlikely to have much effect on the gun debate.”  To me, this statement by Don Braman and Dan Kahan neatly sums up much of what has characterized the gun debate over the last several decades.

Please don’t misunderstand – I’m not opposed to empirical research. But it’s one thing to argue the case for gun risk by citing data which shows that gun injuries increase in homes where there are more guns; it’s another thing to convince individual gun owners that such a finding might apply to any of them. Want to counsel a patient about whether his guns represent medical risk?  You’ll have to figure out how to do it using language which isn’t perceived as a threat.

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