People undoubtedly respected medical professionals. This respect still prevails today, but new influences are undermining patient-physician trust. Sensationalist media, political ideologies, inconsistent CDC guidelines, Google-driven anticipation and “individual research,” impossible insurance plans, and the role of health care in the opioid epidemic, among other effects , all diminish public trust in different ways.
Patients are especially wary of doctors on the subject of gun safety. (Prev Med. 2021;145:106452.) This distrust is rooted in concerns about competence, as firearms safety training was not part of medical training until recently. Many, if not most, gun owners have had firearms training, and doctors who have no firearms experience will easily alienate a patient who may have greater expertise.
Health professionals are led to approach firearms safety from an ethic of care. It’s rarely a good thing when firearms enter the professional sphere of emergency physicians and psychologists like us. We care for patients who have been traumatized – physically and mentally – by the misuse of a firearm, and we may also be potentially traumatized in the process.
We and our patients suffer from the lasting ripple effects of gunshot wounds in our communities, and we routinely assess those with suicidal and homicidal ideation; access to firearms among this population clearly increases the risk to the patient, the community, and us. Emergency services are also among the most dangerous places to work and we continue to see an increasing incidence of workplace violence. The physical presence of firearms among our patients is also potentially threatening.
It is natural for healthcare professionals to strive to prevent device-related harm, but providing context and articulating this philosophy of care is critical when discussing firearms with our patients. Routine or non-contextual investigations of firearm access and storage among our patients, particularly those who do not exhibit risk factors for harm, are easily viewed as intrusive. Carried out on a large scale and recorded in the medical record, which is now happening in various practice settings from California to Massachusetts, it may look like a veiled attempt to create a gun registry, which has been regularly promoted by the gun control advocates.
A culture of autonomy
Many argue that discussing firearms with our patients should be as simple as discussing pool safety, drug storage and seat belts, but the healthcare professions have actually taken a position that undermines the trust. Based on non-causality research demonstrating an association between the presence of firearms in the home and suicide, femicide, and unintentional pediatric injury, healthcare influencers are misinterpreting the device as the cause of the injury, rather than the mechanism, which is more specific.
By attributing gun safety to the device, the medical professions not only reveal a lack of competence, but also imply a judgment that gun owners have made a negligent and dangerous decision to expose themselves and their families to unnecessary harm. Position statements of professional societies, such as the American Academy of Pediatrics, which say “the safest [home] is a house without weapons” – reinforce this attitude and increase the risk of stigmatization. (AAP News. June 21, 2018; https://bit.ly/3Cxol89.)
Guns are part of a culture of self reliance and tradition, and most individuals buy guns to make their homes and families safer. Self-defense training, which by definition includes firearms training, has been shown to decrease fear and improve self-efficacy. (J Appl Psychol. 2000;85:625.) Trust is undermined by the conflict between the healthcare professional’s perspective that “guns make you less safe” and the patient’s perspective that “guns make me safer” .
Our recommendations as medical professionals must be based on evidence, and the data on whether guns make you more or less safe are grossly incomplete and inconclusive. Many people have had experiences where they reasonably believed that access to firearms prevented personal or family harm, and similar anecdotes are widely published in firearms community literature. It is in the best interest of patient-provider trust to approach this issue with objectivity and neutrality and to respect the experience and perspectives of the person we are caring for.
Advising a patient to dispose of their weapons or lock them away so that they are inaccessible may seem like a reasonable security solution for a physician, but chances are patients will hear this as an insulting rejection of identity and individual action. We lose our ability to influence behavior change when we lose the patient’s trust. The impact of our care is reduced without any change in behavior.
Three simple steps can help restore trust between the healthcare and firearms communities about gun safety:
- Build skills in understanding gun ownership and culture, and recognizing that true expertise can lie with the patient. We can increase safety by working with trusted resources within the firearms community, such as retailers, trainers and support networks.
- Frame your lethal means inquiry and advice with why you care: “I’m asking you about access to firearms because I’m concerned about ______.” This recommendation is common sense and evidence-based. (Psychiatric department. 2021;72:898.)
- Make sure discussions about firearms are neutral and objective and consider the person’s unique experiences.
Patients have the autonomy to decide for themselves how they will proceed with their health care decisions. Showing them respect and acknowledging their autonomy is a powerful tool for influencing behavior change. Gun owners, medical professionals and society agree that something must be done to prevent gun deaths and injuries. Let’s all come together to do it. In this way, we will regain trust, respect and our ability to influence change.
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Dr. Barsottiis the director of the AFFIRM program at the Aspen Institute, a program dedicated to reducing firearm injuries in the United States through nonpartisan health-based approaches. He is also a community practice emergency physician at Berkshire Medical Center in Pittsfield, MA, and a certified 4-H Youth Rifle Safety Instructor. Read his past columns onhttp://bit.ly/StandingAFFIRM, find more information about AFFIRM athttps://affirmresearch.org, and follow the foundation on Twitter@ResearchAffirm. Ms Mannis a licensed psychologist and nationally licensed vocational counselor in West Virginia who has focused her career on helping children and adults who have been abused, neglected and abused. She is also an NRA instructor and freelance writer for NRA Women (https://bit.ly/3hY49mt).