"You’d be surprised how many people have guns in their houses," said Dr. Jill Creighton.
As a pediatrician at Stony Brook Children’s Hospital on Long Island, Creighton routinely asks her patients' parents during their children's regular checkups whether or not they own guns -- a question that roughly a quarter of them answer affirmatively.
"There’s a lot of people who have guns for hunting on the tip of Long Island," Creighton said. "Even if they don’t have [guns] themselves, maybe that’s something they should ask a fellow parent if their child is going on a playdate."
For Creighton, asking parents about firearms is a routine part of her practice, she learned while training at Mount Sinai School of Medicine in the 1990s. For many doctors, however, it's far from routine to inquire. There's no good data on how many doctors counsel patients on firearm safety, but according to a new paper published in the Annals of Internal Medicine this week, it's not nearly enough.
"Physicians not only have a responsibility to their patients to diagnose and treat illness, they also have a broader societal obligation to improve population health," Dr. Steven Weinberger of the American College of Physicians wrote in editorial accompanying the paper. In a nation where 33,559 people died of gunshot wounds in 2014, teaching patients about firearm safety needs to be part of that responsibility.
Too few studies have been done on the efficacy of asking about guns for reducing violence to draw any definitive conclusions. But one 72-article meta analysis on clinical firearm screenings published this year found that health care interventions could increase rates of safe gun storage for at-risk individuals.
The authors of that report, which was published in the journal Epidemiological Reviews, noted that current literature on the subject is of low methodological quality and that larger, more rigorous and better-funded studies are needed.
“Physicians not only have a responsibility to their patients to diagnose and treat illness, they also have a broader societal obligation to improve population health.”
But the authors of this latest study defended their recommendations in the face of limited evidence: "Because firearms are the most common means of violent death in the United States, the lack of rigorously validated tools should not, in itself, deter screening," they wrote.
What's more, specific studies yield clearer answers. For example, when families of suicidal teens were counseled by a psychiatrist about firearm access, a third of them removed the firearm from the home. (It's worth noting that there was no control in the study, so we don't know if the families would have removed the guns without counseling.)
Doctors' hesitance to pop the gun question
Even doctors who think they have the right to counsel patients aren't doing it. In one small study, 85 percent of respondents -- all of them members of the American College of Physicians -- agreed that gun violence was a public health issue, with 66 percent of respondents reporting that physicians should have the right to counsel patients on firearm safety. In spite of those responses, more than half of the study participants disclosed that they never asked patients about gun ownership.
"Doctors are, as a group, reluctant to do it," lead study author Dr. Garen Wintemute, a physician who has researched gun violence for more than 30 years, told The Huffington Post.
Some doctors don't feel confident offering safety advice pertaining to a consumer product they've never used. Others believe they might be prohibited by law from talking about firearms (and, in some cases, that's true). Still others don't want to damage clinician-patient relationships by asking intrusive questions. And a few say they don't have the time.
"Nobody questions whether doctors ought to talk about seat belts, or about smoking, or about risk factors for heart disease or cancer," Wintemute said. "Guns are different."
The far reach of Florida's 'Docs vs. Glocks' law
Florida is the only state with a gag law on the books barring doctors from asking their patients about gun ownership, unless the doctor "in good faith believes that this information is relevant to the patient's medical care or safety, or the safety of others" -- a vague loophole that leaves what's "relevant" open to interpretation.
The law, called the Firearm Owners Privacy Act, came as a result of the so-called "Docs vs. Glocks" lawsuit in 2011, which pitted doctors' right to free speech against gun owners' right to privacy and made it a crime for doctors to ask patients about gun ownership outside of the loophole mentioned above. (While the court mulls its final decision on the law, an injunction allows doctors to continue to counsel patients about firearm ownership.)
The lawsuit followed several widely publicized incidents between doctors and patients in Florida. In one such case, an Ocala pediatrician refused to treat three children whose mother declined to answer whether or not she kept a gun in the home.
The publicity surrounding "Docs vs. Glocks," which is being appealed by a group of plaintiffs including medical groups and doctors, seems to have had an effect far beyond Florida's borders. Wintemute said that over the past few years, as he's given talks about physicians' roll in reducing firearm violence, medical professionals in the audience have repeatedly questioned whether they are prohibited from speaking with patients about firearms under the Affordable Care Act or state law.
"Those [suggestions] aren’t true," Wintemute said. "It’s allowed. In fact, it’s protected by the First Amendment."
“Is it loaded? Is it locked? Are there little children present? Is the operator feeling low? Has the operator learned about firearm safety?”- The "5 L's" approach to firearm safety
To guide doctors who haven't yet incorporated questions about firearms into their practice, Wintemute and his fellow authors recommend asking gun owners about the "5 L's" of firearm safety:
- Is it loaded?
- Is it locked?
- Are there little children present?
- Is the operator feeling low?
- Is the operator learned about firearm safety?
In the event a doctor doesn't have time to ask every patient about gun ownership, they should at least screen high-risk patients, such as children and people who are at an increased risk for suicide or violence.
For those patients, the new paper provides a rubric of responses, ranging from critical intervention for patients who are at acute risk for violence to themselves or others to counseling lower- but still at-risk patients, such as middle-aged white men, young African-American men and parents of children, about safe firearm storage.
Public health researchers are unable to study gun violence
“Gun violence is probably the only thing in this country that kills so many people, injures so many people, that we are not actually doing sufficient research on,” Dr. Alice Chen, executive director of Doctors for America, previously told HuffPost.
As The New York Times reported, four toddlers shot and killed themselves in a single week in April.
“This little boy loved to tinker and to play, and he loved to get into things,” Brent Moxey, the pastor who officiated one child's funeral, told the Times. “He loved to figure out how stuff works.”
Gun safety advocates say the reason we're not studying gun violence is largely political -- it's a byproduct of the 1996 Dickey Amendment, which effectively banned the U.S. Centers of Disease Control and Prevention from researching the issue. Since then, more than half a million people have died by firearms, and, devoid of funding, researchers fled the field.
By Wintemute's estimation, there are only about a dozen or so researchers left today who have made a major professional commitment to the subject over the long haul. But despite major policy setbacks, he's hopeful about the future of his field.
"I have been doing this since 1982, and am more optimistic now than at any time -- except perhaps briefly in the early 1990s [before the Dickey Amendment passed]," he said.
In the absence of aid from the federal government, some states and cities are picking up the slack. Seattle approved a tax on guns and ammunition last year to fund gun violence prevention and research. In Wintemute's home state of California, there's a bill being considered to establish a California Firearm Violence Research Center. There's also continuing pressure to make more federal funds available for research.
For now, Wintemute hopes his paper will give doctors the confidence they need to exercise their right to ask patients about health and safety and counsel them accordingly. In the absence of major gun violence research funding, individual intervention from clinicians is one of the only realistic ways to protect patients.
"It's less that we're trying to be Big Brother," Creighton said. "We’re trying to keep children safe."
Language has been added to note that the Florida law is not currently being enforced, pending a court ruling.