Recently both President Obama and the AMA have called for physicians to talk with their patients about gun ownership, especially if they sense mental health issues. This request sounds innocuous enough, but let’s explore the implications and the reality here.

First I need to issue a disclaimer. I am neither a member of the NRA nor do I necessarily feel that more gun laws and bans will reduce the recent tragedies in Newtown, Ct. or Aurora, Co. Gun safety should be of paramount importance to all gun owners. However, if I am going to ask all my patients about gun safety and ownership, then there are a few other dangerous things I need to engage them with as well.

“Do you own a pool?” (Quite relevant since we live in Florida.) “If you do, do you have small children at home or as guests? Do the neighborhood children come by? Do you have a pool fence and is it locked at all times? Have you thought about how many accidental drowning of children there are in Florida every year? Have you taken a course in pool safety?”

Or how about this topic: “Do you own a dog? What kind of dog is it? Were there any pit bulls in its family lineage? Do you have small children at home or grandchildren? Has your dog ever bitten anyone? (Okay, the mailman doesn’t count.) Have you taken a course in dog safety ownership?”

You see where I am going with this of course. First of all, I, and most doctors, don’t have the time to engage in this dialogue with my patients, since I am too busy asking about percentage of seat belt use, quitting smoking, updating medicine lists and system reviews, and filling out ridiculous “meaningful use” of EHR forms, just to get paid from Medicare. And even if I did have time, it is really none of my business. And if even if it was my business, asking this would not prevent a mentally aberrant person from finding weapons and using them in a hideous fashion.

The fatal flaw in this logic is that the desire to do good, does not lead to good results. In fact the opposite is often the case. A recent Opinion piece in the Wall Street Journal, (January 16,2013), by Jeffery Scott Shapiro highlights this paradox. He was a criminal prosecutor in the District of Columbia from 2007-09. In essence, during the strictest gun ban years, the rate of homicides increased. Ultimately in 2007, the U.S. Court of Appeals in D.C. ruled the city’s gun ban to be unconstitutional. The US Supreme Court also affirmed the ruling the next year. Since the ban was struck down in 2008, the homicide rate dropped from 186 to 88 in 2012, the lowest number since the original ban law was enacted in 1976.

Recent shooting tragedies do launch a knee jerk reaction by well-intentioned politicians, but as usual, the beneficial results of new laws often achieve the opposite, since the criminal, or deviant mind, will always find a way to purchase weapons. So following are my thoughts on what might help.

Loosen the HIPAA laws so deranged individuals can have their psychiatric history quickly accessed by mental health providers.  Tighten the “gun show” loopholes, so gun purchases meet the same measures at shows as at a gun store. If the government insists on throwing more money at a problem, (and they excel at always doing so), then invest in more mental health professionals and treatment facilities. Make it easier for teachers, (who want to), learn gun safety and obtain concealed weapons permits. Every adult who supervisors school outings in Israel is trained in weapon use and carry semi-automatic guns on field trips. You never hear about these tragedies in that country.

But mandating doctors to ask patients about gun possession? You can count me out on that one. This is an invasion of privacy, and worse, will do nothing to curtail the periodic catastrophe that occurred at Sandy Hook.

– “To be prepared for war is one of the most effectual means of preserving peace. A free people ought not only to be armed, but disciplined.”
– George Washington, First Annual Address, January 8, 1790.

David Mokotoff founded the Bay Area Heart Center in St. Petersburg, Florida. You can follow him at his personal site here.

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40 Responses for “Lawyers, Guns and Doctors”

  1. john says:

    You may not be a card/gun toting member of the NRA but your argument is specious Leave it up to individual docs, but don’t claim to speak for the majority.

  2. motomed says:

    Thank you for this article!

    You forgot one aspect, though. Literally everyone who does have guns is going to lie to you, so what’s the point? Legal gun owners have zero desire to have this fact logged into another database so they can be tracked, studied, and have their info published in the newspaper, and criminals generally don’t just admit to being criminals. Add to that the reasonable assumption that a doctor isn’t exactly an expert on firearms and is unlikely to have much to offer that a gun owner doesn’t already know, and there is no incentive at all for a patient to participate in this conversation.

  3. Bob says:

    This may interest you. It is from the Patient Protection and Affordable Care Act. http://www.ncsl.org/documents/health/ppaca-consolidated.pdf

    WELLNESS AND PREVENTION PROGRAMS.—A wellness
    and health promotion activity implemented under subsection
    (a)(1)(D) may not require the disclosure or collection of any
    information relating to—
    ‘‘(A) the presence or storage of a lawfully-possessed
    firearm or ammunition in the residence or on the property
    of an individual; or
    ‘‘(B) the lawful use, possession, or storage of a firearm
    or ammunition by an individual.
    ‘‘(2) LIMITATION ON DATA COLLECTION.—None of the
    authorities provided to the Secretary under the Patient Protection
    and Affordable Care Act or an amendment made by that
    Act shall be construed to authorize or may be used for the
    collection of any information relating to—
    ‘‘(A) the lawful ownership or possession of a firearm
    or ammunition;
    ‘‘(B) the lawful use of a firearm or ammunition; or
    ‘‘(C) the lawful storage of a firearm or ammunition.
    ‘‘(3) LIMITATION ON DATABASES OR DATA BANKS.—None of
    the authorities provided to the Secretary under the Patient
    Protection and Affordable Care Act or an amendment made
    by that Act shall be construed to authorize or may be used
    to maintain records of individual ownership or possession of
    a firearm or ammunition.

  4. What George Washington said is irrelevant because a bunch of white men with rifles don’t make an army nowadays. Militia days are over, just like many other things from that era are over.

    That said, I find it pathetic that our best solution to the guns issue is to have doctors look for people that may be mentally ill and “counsel” them on gun ownership. First, in my opinion, anybody who feels the need to own firearms is most likely mentally ill to a certain degree, including those who define “sport” as killing something. Second, doctors are not qualified for the job, and we need to stop medicalizing everything, pools, dogs, fire extinguishers and helmets included.
    It is the legislators’ job to put an end to this particular type of plague, so they just need to do their job for a change.

  5. Carla Kakutani MD says:

    The author must not be a family physician or pediatrician. What do we ask about during well child visits? Safety, and that includes pool/water safety, car/bicycle safety, gun safety and red flags for mental illness and domestic violence, which threatens the safety of everyone in the home.
    If this is news to you, Dr Mokotoff, then you don’t know much about primary care.

    • Carla,

      You are correct. I am an adult Cardiologist. My concern is that government rules tend to mandate everybody act the same. Your questions for parents of a child are appropriate of course. However, the AMA and the POTUS implied that all doctors ask about guns. You also forgot about dogs. I believe more children are injured every year by this than guns.

      David

  6. joe says:

    Margalit – to quote you “in my opinion, anybody who feels the need to own firearms is most likely mentally ill to a certain degree”

    Would I be offensive if I said, “I pray to God that every politician who feels like you do (a good number of Democrats currently office, seeking office, and who aspire to higher office) — has the temerity, as you do — to go on national and local television and say that into the camera?”

    • Not offensive at all, Joe. I think people should state their opinions publicly before we elect them, assuming they actually have any opinions, instead of saying whatever it takes to get elected and then assuming the opinions of whoever pays them the largest amount of money.

      • Margalit:

        If this is your opinion, then you might be interested what Joe Biden said about then candidate Obama in 2008 and guns:
        “I guarantee you Barack Obama ain’t taking my shotguns, so don’t buy that malarkey,” Biden said Saturday at the United Mine Workers of America’s annual fish fry in Castlewood, Virginia. “Don’t buy that malarkey. They’re going to start peddling that to you.”

        Biden told the crowd that he himself is a gun owner. “I got two,” Biden said, “if he tries to fool with my Beretta, he’s got a problem. I like that little over and under, you know? I’m not bad with it. So give me a break. Give me a break.”

        • I am not at all surprised, Dr. Mokotoff, because contrary to the NRA and lunatic fringe PR campaign, neither the President nor the Vice President are out to take away anybody’s guns. Unfortunately.

          • motomed says:

            correct, because it isn’t a political reality. If it was, they’d be all for it.

            “While a state senator, Obama voted for a bill that would ban nearly every hunting rifle, shotgun and target rifle owned by Illinois citizens. That same bill would authorize the state police to raid homes of gun owners to forcibly confiscate banned guns.”

            “While a state senator, Obama voted 4 times against legislation that would allow a homeowner to use a firearm in defense of home and family.”

            http://www.speroforum.com/a/16427/Obamas-guncontrol-history-in-the-Illinois-Senate

            The NRA’s PR campaign on this consists of using actual voting records and quotes from politicians when they speak of confiscation…..

            Tell me more about a third of the country being crazy…. it makes your opinions carry that much more weight.

  7. The question has been on the DSHS patient intact forms for over a decade. The PPACA doesn’t stop that collection. It only ‘affects’ wellness and preventative services – nothing of pallative, on-going treatment, treatment due to illness, injury, accident, administration of RX nor psychotherapy / counseling. You think they are not going to be attempting to collect that info ? well only form the sheep that wont lie about it.

  8. Sandi Brewer says:

    The other questions we ask our patients aren’t a matter of Constitutional rights, but gun ownership is. I will NOT ask my patients this. It is not my business, nor is it yours. And I will not answer it either. The Government bribes us with Medicare payments to inform on our patients; it is truly despicable.

  9. bmore_bulldog says:

    There are a few simple steps one can take to make a gun in the home safer: store the gun in a location not easily accessible to children, store ammunition and gun separately, lock the weapon away if others know where it is, avoid having access to a gun while experiencing suicidal ideation, etc. This makes asking about gun ownership and safety a potentially highly effective public safety intervention. Gum safety can and should be discussed because, like seat belts, one can take relatively simple steps to greatly reduce risk of harm.

    What makes this issue particularly frustrating is that the NRA and other gun rights advocates have been interfering with the patient-physician relationship for a decade now. The most galling recent case is the NRA-supported Florida legislating banning physicians from discussing guns with their patients. Note, of course, that there is no flip side to the coin; no public health advocate or government official has ever suggested MANDATING that physicians discuss guns with their patients, despite conservative howls to the contrary.

    Furthermore, for several decades there has been a de facto freeze on epidemiology and research on gun violence through the CDC and NIH. With the recent Obama executive order there is finally some pushback on this too broadly interpreted statute.

    Before conservatives howl about anti-gun advocates pushing doctors to discuss guns with their patients, they should acknowledge that only the pro-gun lobby has attempted to directly legislate physician and scientist behavior.

    • motomed says:

      the fact of the matter is that the measures you suggest would prevent an incredibly small fraction of gun deaths and as such it’s hard to justify spending the time having these conversations. The facts just don’t support the notion of there being that many children killed by accident. an overwhelming number of gun deaths are the result of people choosing to point a gun at someone and pull the trigger.

      How many kids are killed by furniture or flat screen TV’s falling on them?

      The list of things that kill more children than accidental discharges of guns is long, this is being bumped up that list for political reasons.

      I don’t support legislation or politicians suggesting anything on the issue, butt out…. let the conversations doctors choose to have be guided by data.

      • bmore_bulldog says:

        We actually don’t know how many deaths we can prevent with such interventions, because there are restrictions on physicians, epidemiologists, and scientists studying these questions.

        Considering how many suicides are committed with handguns, my last suggestion alone could save many, many lives. Psychiatrists should definitely know if their patients own a gun, but so should internists. But the bottom line is we don’t really know, partially because the NRA has pursued a policy of restricting research on the subject.

        We all have a second amendment right to own guns. But we also have a right as physicians to discuss what we feel is appropriate with our patients, and as scientists to understand how we can improve public health. Gun rights advocates have had little respect for those rights.

        • motomed says:

          excluding suicide, we know exactly how many deaths we could possibly prevent because we know how many kids die from unintentional firearm injuries. Old data but I’m too bored to find more recent. For this year, there were 22 million children under the age of 18 living in homes with guns, and 214 of them were unintentionally killed. Nobody would suggest such a rate requires across the board intervention based purely on a public health perspective. An overwhelming number of “children” who are killed by guns are teenage criminals.

          http://www.med.umich.edu/yourchild/topics/guns.htm

          Psychiatrists and internists dealing with mental health issues already ask these questions, and nobody is suggesting they shouldn’t. I have said previously that no group with an agenda on a particular issue should have anything at all to say to physicians about how to do their job.

          Public health research involving guns doesn’t happen anymore because those doing it previously made it incredibly easy for folks like the NRA to demonstrate how biased they were. Criminologists agreed, it was just propaganda.

          Which amendment is it again that gives scientists the right to use public funds for anything at all? Nobody is stopping you from doing the research, they just aren’t necessarily paying you to do it.

          An NRA certified instructor that I have trained with gives all his students his phone number and makes it clear to them that if they ever find themselves in a depressed state, going through a divorce, etc, to give him a call and he’ll hold onto their guns for them until the trouble passes. The NRA does far more for gun safety than anyone gives them credit for.

          • steve says:

            Nope, criminologists did not agree. The problem was that some of the data suggested that the risk of dying was higher if you have a gun in the house.

            Kudos to your NRA instructor. I have done the same for others. When my brother in law was suicidal I got the guns out of my house. Now that he is dead, couldnt afford his medications, I have them back.

            Steve

          • motomed says:

            Some of the data, definitely, but it wasn’t difficult at all to question the data and the intentions behind it. If honest inquiry and scholarship were guiding public health research on the topic 20 years ago, there never would have been an issue and the funding would have never been pulled. It’s not accurate at all to say the NRA just starting fighting research funding because they didn’t like the results and politicians were suckered into doing whatever the NRA wanted. Their were valid concerns that anyone wishing to do similar research now should admit and speak out against if they wish for their work to have any impact on those not already in agreement with them.

            Public health initiatives have the power to do great things, but they also run the risk of totally marginalizing the entire field if they allow their science to become motivated by politics. I don’t want to see that happen.

            http://www.constitution.org/2ll/2ndschol/58tenn.pdf

            http://www.drgo.us/?p=266

            http://www.drgo.us/?p=285

  10. Why is it that every time people decide to “do something” it’s always aimed at the doctors? When the issue of narcotic abuse comes up, it’s the doctors that need training in their use instead of holding the people taking the pills accountable. When seat belts were shown to reduce deaths it suddenly became a “quality measure” that all doctors ask about seatbelt use. Same with smoking. Gun use is just another of these personal decisions that become the doctors responsibility.

    • Very well said. And here is another one from the USPSTF, which assigned a grade B to IPV screening for all women of child bearing age because it is a “significant and largely unaddressed public health problem.”
      IPV stands for Intimate Partner Violence, and until today, I was under the impression that raping and beating women was a serious crime, not a health problem.

    • Shirie:

      Agreed. I could not have said this better.

      David

  11. motomed says:

    If a drug company openly donated a billion dollars to a university that was responsible for turning out the bulk of the research that supports that drugs usage, do you think people would mind?

    http://hub.jhu.edu/2013/01/26/bloomberg-gift

    gun control is losing hard on the political front and has been for years so they’re trying to rebrand it as a public health issue. it’s up to us whether or not we want to be pawns or whether or not we’d like to have the field of public health maintain some shred of integrity and relevance.

  12. Legacy Flyer says:

    I agree with Dr. Mokotoff about what the role of a physician should be. I am not a primary care doctor (thank god), so I am not subject to the attempts of various (well meaning?) people to “task” me with carrying out their pet agendas.

    Various questions I will NOT be asking:

    - Have you labeled your forks with a warning saying: “Do not stab these into your eyes repeatedly”?

    - Have you ever taken an aluminum step ladder out into a field during a thunder storm and stood on top holding a copper rod?

    - Do you plan to give your 16 year old son a bottle of whiskey and the keys to a Corvette?

    If you answer to “NO” to all the above you are a normal person with normal intelligence. If you don’t, well ……

    “You can’t fix stupid”

    • steve says:

      Yes. All of these are exactly like….

      “You are being treated for a major depression. Do you have any guns at home?”

      Steve

      • Lecaia713 says:

        If I am being treated for major depression, yes, it is a valid question. If I am going in for my yearly gynecological exam, how does my ownership of guns factor in to any treatment I might need? That’s the issue, here. Not every doctor a person might see needs that information, but they are required/encouraged to ask anyway.

  13. @motomed
    If it’s only a “third of the country”, and I thought it was more than that, then the other two thirds ought to make this a “political reality” in a true democracy. I wonder what is stopping the majority of the people from enacting policy…..

    • motomed says:

      fortunately plenty of people recognize that even though they may not be particularly interested in something, that doesn’t mean they should support a government ban on it…. And even if you could mobilize them, we live in a constitutional republic, not a democracy, a fact that was once again pointed out to barack obama last friday by a federal court…. Ask DC and Chicago how their democratically arrived at handgun bans worked out…

  14. Asking people about firearms has been part of the dangerousness assessment in psychiatry since I took the boards over 20 years ago. You would not have passed the oral boards if potential dangerousness was not assessed. People can lie to you but in clinical practice there is also clear evidence that having this discussion, not with the patient but also their family makes a difference. In 22 years of acute inpatient care, I cannot imagine releasing a patient I treated for suicidal or aggressive ideation back home without a high degree of certainty that there were no guns there. The idea that there is something else going on with those discussions than trying to assure patient safety is nonsense.

  15. Peter1 says:

    Armed guards in schools and classrooms, theaters, sports stadiums, shopping malls, workplaces and everyone armed – literally everywhere. Yes, Afghanistan of the U.S.A., now that’s the definition of a successful country brought to you by the gun industry.

    You’re all freaking NUTS!

  16. steve says:

    I was still in the military when we saw the beginning of the increase in suicides. I have had to call and speak with the fiance of a man who killed himself. We know that suicide is often an impulsive act. We also know that the Israelis, when faced with suicide as a problem among their military, decreased its frequency when they stopped letting people take their guns home with them on w/e’s. Gun rights absolutists dont want responsible officers to be able to ask soldiers if they weapons at home. Better we have people die than offend a few by asking them if they have guns at home.

    Steve

  17. BobbyG says:

    I would repeal the 2nd Amendment and replace it with something that makes sense today and going forward.

    http://bgladd.blogspot.com

    I know, isn’t going to happen.

  18. john says:

    How about the people who regularly show road rage and also those who will not stop drinking and driving.Im sure it would be a good deterent for DWI deaths and accidents.If they don’t wise up take away their guns before you even consider a person who suffering from a nervous condition and almost always is harmless.

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  21. Ben Scoutara says:

    Doctors have a lot on their plate and are starting to be asked to step into arenas that they may not be exactly qualified for. But if giving a doctor this responsibility to ask those questions and document it in the patient’s chart saves one life, that’s it’s probably worth it. Everyone really needs to step up to make this world a better place, not just physicians.

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