Yes, You Can: Physicians, Patients, and Firearms

[Guyton]

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http://annals.org/article.aspx?articleid=2522436

I am considering adding a firearms screening question to my evaluations. Thoughts?

 

[vistaril]

http://annals.org/article.aspx?articleid=2522436

I am considering adding a firearms screening question to my evaluations. Thoughts?

I haven't had a lot of patients that I thought shouldn't have a gun. I guess it depends on settings though. I pretty routinely talk about guns with some of my patients the same way I would talk to them about football or grilling or whatever.

 

[hamstergang]

Having a gun available is a significant modifiable risk factor for suicide (and fatal accidents, I'd guess, but I haven't looked at that research ever). I don't see a reason to treat it differently than any other modifiable risk factor.

 

[Wilf]

Having a gun available is a significant modifiable risk factor for suicide (and fatal accidents, I'd guess, but I haven't looked at that research ever). I don't see a reason to treat it differently than any other modifiable risk factor.

The main problem is that it would be a lot of wasted time because few patients would give up their guns. Also I think that society to some degree still looks up to physicians and I don't think it would be wise to come off as anti-gun.

 

[Shikima]

Routine screening, no. Crisis/safety intervention - absolutely. Nothing wrong with having a safety talk at the correct moment.

 

[MacDonaldTriad]

If you believe that a physician’s role includes reducing morbidity by using prevention, we should all be anti-gun. Even with all of the self-protection arguments, people are more likely to be injured if they have a gun vs if they don’t. I’m not saying that you are a bad physician if you are pro-gun, but if you look at data in an objective way, this is still true. The numbers have nothing to do with the mentally ill so nothing is likely to change.

 

[vistaril]

The main problem is that it would be a lot of wasted time because few patients would give up their guns. Also I think that society to some degree still looks up to physicians and I don't think it would be wise to come off as anti-gun.

I didn't read hamster's post to mean we should be encouraging patient's to give up their guns.

I think there are a small number of patients who probably shouldn't have guns. If I have a patient in that group, I'll encourage them to. But certainly the vast majority of patients should enjoy their guns millions of other americans do.

 

[wolfvgang22]

The suicide screenings we have to do every 6 months on every patient that comes to my VA clinic asks whether the veteran has access to firearms or not. I've had only three or four patients take offense to my asking about if they have a firearm, and whether they should. Interestingly, those few who took offense are generally those with strong cluster B traits and feelings of powerlessness in their lives, and say stuff like "ain't nobody gonna take my guns, I might need them for the revolution. That Muslim Obama is going to outlaw all guns, he is going to establish dictatorship and never leave office, but I'll have MY guns." Ok. I then screen for psychosis. If none, we move on.
Nobody has fired me over the gun question. I make sure they know I care about their safety, not their politics. Usually if they later fire me it is because I won't prescribe endless Xanax 1mg PO QID for PTSD or hip pain or whatever.

 

[vistaril]

The suicide screenings we have to do every 6 months on every patient that comes to my VA clinic asks whether the veteran has access to firearms or not. I've had only three or four patients take offense to my asking about if they have a firearmQUOTE]

When I had to do those, I usually(depending on the patient) made it into a positive. Obviously it's not unusual for vets to have very impressive collections, and I've noticed that they tend to be appreciative when I take a genuine interest in their passion.
Actually there were a few vets who if they didn't get a new gun for Christmas I'd be concerned about depressive symptoms because to me that would indicate a lack of interest in previously enjoyable positive activities.

 

[WingedOx]

I didn't read hamster's post to mean we should be encouraging patient's to give up their guns.

I think there are a small number of patients who probably shouldn't have guns. If I have a patient in that group, I'll encourage them to. But certainly the vast majority of patients should enjoy their guns millions of other americans do.

Yeah, I only really have two patients whose possession of a firearm makes me nervous because of their mental health. The others few that make me cringe are because of basic negligence. (umm, sir, you just told me that that your grandchildren come over frequently and play in your house, but you just told me that you leave your loaded pistol on your bedside table.")

I talk guns with a lot of my patients in the outpatient setting just as anything else. It's not so much being anti-gun or pro-gun as it is making sure people aren't doing anything preventable and stupid.

 

[WingedOx]

"ain't nobody gonna take my guns, I might need them for the revolution. That Muslim Obama is going to outlaw all guns, he is going to establish dictatorship and never leave office, but I'll have MY guns." Ok. I then screen for psychosis. If none, we move on.

In my clinic, that's not a sign of psychosis, it's a sign the patient lives in McHenry County.

 

[hamstergang]

I didn't read hamster's post to mean we should be encouraging patient's to give up their guns.

Correct. While I am personally rather anti-gun, that doesn't play into my doctoring and I know I'll never convince someone with a gun to give it up.

But there are other steps that can be taken to help secure a gun and reduce the risk of accidents or impulsive fatal acts. I also imagine that documenting a conversation about this would make our lawyers happy.

 

[erg923]

The main problem is that it would be a lot of wasted time because few patients would give up their guns. Also I think that society to some degree still looks up to physicians and I don't think it would be wise to come off as anti-gun.

Psychiatry is criticized for being slow to the the prevention table, and heavy-handed in their reactions to psychopathology or behavior that is preventable with early, generally non-medication based, methods.

Again, this is all about assessing risk factors in my mind. Its standard information gathering, and it always will be for me. I dont understand this controversy in the slightest.

I see many patients who have readily turned over control of weapons to spouses, children, etc.

 

[birchswing]

Should be something pediatricians ask parents about as well, in terms of making sure guns are locked away. It's an environmental risk factor for death.

 

[clausewitz2]

In my clinic, that's not a sign of psychosis, it's a sign the patient lives in McHenry County.

Quick way to assess anhedonia in Eastern Kentucky: "And when was the last time you went hunting or fishing?'"

 

[OldPsychDoc]

Should be something pediatricians ask parents about as well, in terms of making sure guns are locked away. It's an environmental risk factor for death.

Like car seats.

 

[Bartelby]

The main problem is that it would be a lot of wasted time because few patients would give up their guns. Also I think that society to some degree still looks up to physicians and I don't think it would be wise to come off as anti-gun.

Giving up their gun forever, maybe not. But if you have a sincere conversation about the reasons why you want a family member holding their gun in a different location for a bit while they move into a better mental space I have found patients to be receptive. You then call the family member, explain the reasoning as situationally appropriate, and get the gun at someone else's place temporarily. That way when the patient is feeling drunk and impulsive one night the barrier to shooting himself in the head is at least higher.

 

[WingedOx]

Sometimes I do think that everyone who's working with a VA population (or similar) should be required to go out to the range at least once. I'm a "leftist gun grabber" and have no delusions about needing a gun for personal self-defense but I do understand when my patients tell me that they like shooting to relax. Target shooting requires you to tune all distractions out and be mindful of only one very focused activity if you want to be accurate, something a lot of these PTSD guys have trouble doing in other settings.

 

[WisNeuro]

Sometimes I do think that everyone who's working with a VA population (or similar) should be required to go out to the range at least once. I'm a "leftist gun grabber" and have no delusions about needing a gun for personal self-defense but I do understand when my patients tell me that they like shooting to relax. Target shooting requires you to tune all distractions out and be mindful of only one very focused activity if you want to be accurate, something a lot of these PTSD guys have trouble doing in other settings.

Just as long as we don't use it for an amateur attempt at an exposure exercise (e.g.,l Chris Kyle).

 

[sunlioness]

Just make sure you don't practice in FL. It's illegal to ask there.


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[Guyton]

Thank you all the input.

Just make sure you don't practice in FL. It's illegal to ask there.

I do not practice in Florida. However, the Florida statute allows for asking about firearms when the physicain, in good faith, believes that this information is relevant to the patient's medical care or safety, or the safety of others.

 

[erg923]

Just make sure you don't practice in FL. It's illegal to ask there.


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Illegal?

First, how would this be enforced and what would the penalty be? Second, I've never heard of a clinical question be deemed "illegal." That doesn't even make any sense to me. What the rationale? That people would be offended or something?

 

[splik]

Illegal?

First, how would this be enforced and what would the penalty be? Second, I've never heard of a clinical question be deemed "illegal." That doesn't even make any sense to me. What the rationale? That people would be offended or something?

Yes there was a big case where this was shot down based on violation of the 1st amendment and is an example of a large number of cases in the clinical arena that are abusing the 1st amendment to interfere in clinical practice (abortion and reparative-therapy legislation has also been so challenged). In FL you could face disciplinary action by the medical board and lose your license. It doesnt apply to psychiatrists though

 

[hamstergang]

Illegal?

First, how would this be enforced and what would the penalty be? Second, I've never heard of a clinical question be deemed "illegal." That doesn't even make any sense to me. What the rationale? That people would be offended or something?

It's FL. That should be explanation enough.

 

[deleted343839]

Illegal?

First, how would this be enforced and what would the penalty be? Second, I've never heard of a clinical question be deemed "illegal." That doesn't even make any sense to me. What the rationale? That people would be offended or something?

There was an editorial about these laws in JAMA last year: http://jama.jamanetwork.com/article.aspx?articleid=2278595

 

[MacDonaldTriad]

Jeb's brother made ECT illegal in Texas I hear.

 

[vistaril]

Just make sure you don't practice in FL. It's illegal to ask there.


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even if I move to florida, I plan on asking many patients there about their guns.....of course the nature of the conversation would make it clear what my intent is(to talk shop and build rapport).

 

[WingedOx]

even if I move to florida, I plan on asking many patients there about their guns.....of course the nature of the conversation would make it clear what my intent is(to talk shop and build rapport).

I plan to do it as part of a vast UN conspiracy to take their guns away and create one world government. Different strokes for different folks I guess.

 

[erg923]

I plan to do it as part of a vast UN conspiracy to take their guns away and create one world government. Different strokes for different folks I guess.

Sup...

 

[notdeadyet]

Sometimes I do think that everyone who's working with a VA population (or similar) should be required to go out to the range at least once. I'm a "leftist gun grabber" and have no delusions about needing a gun for personal self-defense but I do understand when my patients tell me that they like shooting to relax.

I'll sign up all the leftist gun grabbers for mandatory time at the range. Just so long as I can sign up all the right-wing 2nd Amendment extremists to spend time in counseling sessions for parents of dead kids killed by firearms.

Yours in the middle, NDY

 

[vistaril]

I plan to do it as part of a vast UN conspiracy to take their guns away and create one world government. Different strokes for different folks I guess.

I'll sign up all the leftist gun grabbers for mandatory time at the range. Just so long as I can sign up all the right-wing 2nd Amendment extremists to spend time in counseling sessions for parents of dead kids killed by firearms.

Yours in the middle, NDY

eh....doesn't sound very middle to me. 1) Believing in the bill of rights is not 'extremist'. In fact I would argue that not believing in the bill of rights is extremist. 2) I have no interest in signing up for the sort of counseling sessions you mention because I understand and practice gun safety already. Every responsible gun owner I know doesn't allow their toddler to have access to their firearm, so it's not an issue.

 

[WisNeuro]

Meh, everyone's a "responsible gun owner." Until they aren't. It's kind of a meaningless term.

Signed,
A responsible gun owner

 

[deleted480308]

Illegal?

First, how would this be enforced and what would the penalty be? Second, I've never heard of a clinical question be deemed "illegal." That doesn't even make any sense to me. What the rationale? That people would be offended or something?

politically speaking it was a reaction to how medicine/politics have become a lot more friendly when it comes to working together against gun rights. A number of the specialty groups have let out some pretty hard line anti-gun position/opinion papers and there is an increase political call to use mental health records to determine gun rights which coupled with EMR proliferation has people concerned that their doctors are contributing to a defacto gun registry.

 

[WingedOx]

I'll sign up all the leftist gun grabbers for mandatory time at the range. Just so long as I can sign up all the right-wing 2nd Amendment extremists to spend time in counseling sessions for parents of dead kids killed by firearms.

Yours in the middle, NDY

Eh, my point was mostly that I see a lot of MH professionals who freak out about patients using range shooting as a hobby. Would it be ideal if they did something else? Sure, but the guys I see who hit the range once a week are a lot less careless with their firearms than the guys who only "need them for protection."

I also see people who see shooting as some sort of "letting out aggression" which doesn't really match up with reality.

 

[erg923]

politically speaking it was a reaction to how medicine/politics have become a lot more friendly when it comes to working together against gun rights. A number of the specialty groups have let out some pretty hard line anti-gun position/opinion papers and there is an increase political call to use mental health records to determine gun rights which coupled with EMR proliferation has people concerned that their doctors are contributing to a defacto gun registry.

All medical or MH provider should be "anti-gun" if they increase risk of mortality to our patients in their situation. Why is this controversial? I don't see nutritionist being "pro" fast food. Whats the difference? Both are risk factors.

 

[vistaril]

Eh, my point was mostly that I see a lot of MH professionals who freak out about patients using range shooting as a hobby. Would it be ideal if they did something else? Sure, but the guys I see who hit the range once a week are a lot less careless with their firearms than the guys who only "need them for protection."

it's completely irrelevant why someone 'needs' their guns. I know people with > 100 guns who haven't shot any of them in the last year. They have just as much right to enjoy their guns as someone who has 4 guns and hunts/goes to range 3x week does.

 

[WingedOx]

it's completely irrelevant why someone 'needs' their guns. I know people with > 100 guns who haven't shot any of them in the last year. They have just as much right to enjoy their guns as someone who has 4 guns and hunts/goes to range 3x week does.

oh god, let's not start THAT thread again.

 

[vistaril]

Meh, everyone's a "responsible gun owner."

Well actually no. The vast majority of people are.

 

[vistaril]

oh god, let's not start THAT thread again.

no intention of doing so.....was simply responding to someone else. It just speaks to the language the left uses, and how they don't even understand the issue well enough to speak about it. Whenever anyone on the left starts to qualify how we use are guns, they are automatically disqualified from the conversation imo. Whenever a politician rambles on about hunting or skeet shooting or some other bs, they automatically get identified as someone who isn't going to be taken seriously on the issue because they aren't even speaking the same language.

 

[deleted480308]

All medical or MH provider should be "anti-gun" if they increase risk of mortality to our patients in their situation. Why is this controversial? I don't see nutritionist being "pro" fast food. Whats the difference? Both are risk factors.

because by that standard all doctors should oppose cars because walking is safer, or bats, or knives....it's silly to assume that my profession means I want to control every aspect of my patient's life. Their guns are their right and I don't need to have an opinion on them at all until they are mentally infirm enough to be dangerous with a knife.

Well actually no. The vast majority of people are.

CWP holders are dramatically safer than the general population

 

[WisNeuro]

Well actually no. The vast majority of people are.

The vast majority are. Nearly 100% will claim to be if asked.

 

[vistaril]

it's like when some politician says "if you hunt or target shoot, we don't want to take that away from you at all".......well, does that imply they do want to take away my right to buy a Marlin BFR just to hang up in my gun room so I can make my neighbor who bought the desert eagle 50 jealous and 'one-up' him? Because that is sure as hell my right too. We don't *need* a reason.....other than we want to.

 

[WingedOx]

If you want to have a political/2nd ammendment discussion, wander over to SPF. If you want to have a grownup (if somewhat snarky) discussion about how we handle a modifiable risk factor in this profession regardless of our opinions on the second opinion, go back to what we were doing before...

I honestly don't give a **** why my patient has a gun, but as I mentioned before, I've had a couple cases where the patient has been SERIOUSLY negligent with firearms. I need to cover my ass appropriately in those situations, particularly in the "outrage-based medicine" practiced in my setting.

 

[vistaril]

The vast majority are. Nearly 100% will claim to be if asked.

your argument then goes towards the fact that some people lie and or have poor insight. That doesn't mean there aren't irresponsible and responsible gun owners.

 

[erg923]

because by that standard all doctors should oppose cars because walking is safer, or bats, or knives....it's silly to assume that my profession means I want to control every aspect of my patient's life. Their guns are their right and I don't need to have an opinion on them at all until they are mentally infirm enough to be dangerous with a knife.

Well, I think most doctors would advocate walking vs driving (when realistic/pragmatic), and should be concerned about knives when persons are having SI or HI. That seems very logical. Whats your beef with that?

People rights don't suddenly make my job description disappear, right? You have right to own guns. I also have right to ask you if you own guns. Certain laws allow authorities to restrict that right for purposes of safety of self and others. Again, what's people the beef with this? I don't get?

 

[WisNeuro]

your argument then goes towards the fact that some people lie and or have poor insight. That doesn't mean there aren't irresponsible and responsible gun owners.

There are plenty of both, but even the responsible ones do stupid **** now and then. Merely pointing out that the term is largely meaningless in teh grand scheme of things.

 

[vistaril]

If you want to have a political discussion, wander over to SPF. If you want to have a grownup discussion about how we handle a modifiable risk factor in this profession regardless of our opinions on the second opinion, go back to what we were doing before...

I wasn't the one who started it drifting political(by the way...it's really not a 'political issue'.....it will only be a political issue when the left wants to try to change the constitution....I think there is a process for that, so good luck with it hehehe).

But concerning the clinical aspects of it, sb247 has it right. There are literally hundreds of 'modifiable risk factors' for morbidity and mortality. Me driving home today in the rain is one. I'd be safer if I waited here for 3 more hours and then drove on clear roads. But of course I'm not going to do that because the increased risk is more than offset by the convenience and desire to get home. Just like the vast majority of my patients are going to enjoy the benefits of guns to them. Now I imagine if there was a tornado coming through right now I'd probably wait it out before driving home, because then the balance would swing. And likewise if I had a patient who is clearly not stable enough to have a gun, then that balance would swing as well.

 

[erg923]

I wasn't the one who started it drifting political(by the way...it's really not a 'political issue'.....it will only be a political issue when the left wants to try to change the constitution....I think there is a process for that, so good luck with it hehehe).

But concerning the clinical aspects of it, sb247 has it right. There are literally hundreds of 'modifiable risk factors' for morbidity and mortality. Me driving home today in the rain is one. I'd be safer if I waited here for 3 more hours and then drove on clear roads. But of course I'm not going to do that because the increased risk is more than offset by the convenience and desire to get home. Just like the vast majority of my patients are going to enjoy the benefits of guns to them. Now I imagine if there was a tornado coming through right now I'd probably wait it out before driving home, because then the balance would swing. And likewise if I had a patient who is clearly not stable enough to have a gun, then that balance would swing as well.

Not all risk factors are equal, right? Look at the suicidology lit. Its in the top 3!

 

[deleted480308]

Well, I think most doctors would advocate walking vs driving (when realistic/pragmatic), and should be concerned about knives when persons are having SI or HI. That seems very logical. Whats your beef with that?

People rights don't suddenly make my job description disappear, right? You have right to own guns. I also have right to ask you if you own guns. Certain laws allow authorities to restrict that right for purposes of safety of self and others. Again, what's people the beef with this? I don't get?

when the specialty groups publish papers asking for legislation to restrict those rights, it causes those who support their rights to lose trust.

if all physicians wanted to do was say, "hey man, you're pretty depressed right now...do you have a firearm? do you think you should give that to your brother for a bit?" then it would be fine......but some of those in group leadership want to go far past that it gets a reaction

 

[vistaril]

Not all risk factors are equal, right? Look at the suicidology lit. Its in the top 3!

yes and the per year suicide rate is still 13 per 100,000 per year or so. So you are talking about reducing that *some fraction* of that.(yes I know the people you would be concerned about have a higher rate than this, but again we are still talking about *some fraction* of even that higher rate in terms of reduction).

I know if I had a choice between reducing my risk of death in the next year by 10/100,000(and I believe that would be a high number) or having access to guns.....well, that would be a very easy choice.