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Wednesday, January 1, 2014

Cultural Competence and Firearms

Disclaimer: The following is a (long-winded, rambling) opinion piece which reflects the views of the author only, and does not necessarily reflect the position of her business partners, her hospital, her state medical society, the institution that trained her, her great-grandmother's hairdresser, or her deceased cat.

Let me start off with a definition - "Cultural Competence". The concept of cultural competence or cultural awareness is a very important one in the field of medicine and patient care. Put simply, it involves being aware of, respectful of, and sensitive to, the culture of the population that one serves. This is an important component of effective patient care, whether one is practicing in Alaska, Puerto Rico, or Appalachia.

As important as this concept is, I'm going to go out on a limb here, and make the assertion that most of the medical community in general and the pediatric community in particular - is lacking in cultural competence when it comes to firearms.

If this statement gives you the vapors, I will refer you to to the official position of the American Academy of Pediatrics as an example, so you can see for yourself.

http://www.aap.org/en-us/advocacy-and-policy/state-advocacy/Documents/Firearms_SLR.pdf

"Firearms Safety
AAP Policy
In 2012, the Academy reaffirmed its commitment to advocating for the strongest possible firearm
regulations. The absence of guns in homes and communities is the most reliable and effective
measure to prevent firearm-related injuries in children and adolescents. The AAP supports a number of specific measures to reduce the destructive effects of guns in the lives of children and adolescents, including the regulation of the manufacture, sale, purchase, ownership, and use of firearms; a ban assault weapons; and expanded regulations of handguns for civilian use. To prevent gun-related death and injuries, the AAP recommends that pediatricians provide firearm safety counseling to patients and their parents."

Now, I don't know about you, but I live in semi-rural Appalachia. Despite the actions of a certain U.S. senator, most of the people here love their guns. So much so, that the mascot of our state university carries, and regularly fires off, a real, functioning firearm at university sporting events. And yes, he even carries it into elementary schools. And you know what? Nobody bats an eye. Why? Because firearms are a traditional and accepted part of the culture here. It's a part of "my" culture as well. I became a pediatrician before I ever became a gun owner, but it wasn't a big deal because culturally, I was already "there" - I was surrounded from childhood with hunters and firearms owners. There are many, many people here who own many, many types of firearms for many different uses - including for "plinking", for target competition, for skeet/trap/sporting clays, for self-defense, and for putting meat on the table. Firearms are a normal, everyday part of life for people here. As, indeed they are for many millions of other Americans across the country.

We can't all be brushed off as "Bitter Clingers"  or "Ignorant Rednecks" either. Some of us are only "conservative" politically when it comes to the 2nd Amendment. A few of us even voted for the current president. Some of us have multiple advanced degrees. Some of us are in positions of authority. Some of us are in the public eye. Some of us practice law, or medicine, or nursing. Some of us are First Responders. Some of us are school teachers. Some of us even work for the government. And 99.999...% of us will never become criminals or mass-murderers.

So. Having recognized that this culture prevails not only here, but in wide swaths of the country, why in heaven's name does the medical community espouse legislating DISARMAMENT as their selected means of "protecting children"?

Because apparently they are Culturally Tone Deaf.

Now, it's important to understand that most docs, (and pediatricians in particular) didn't get into the business because they are mean, controlling people. On the contrary, they love kids, and want to do everything in their power to help kids grow into healthy, strong, responsible adults.  They are compassionate people - I just think that their compassion is misdirected when it comes to firearms. I understand and share the motive to protect the youngest generation, and I understand that research suggests that the human brain hasn't completely matured until the early 20's -- but including 19-24 year-olds in "child" data? I'm sorry, but a 20 year old gangbanger killed in a shoot-out is not a "child" - he is adult enough to be a criminal. Including data like that in child statistics seems a little intellectually dishonest to me.

Likewise, a 17 or 18 year-old burglar killed by a homeowner is a criminal who shouldn't be included in "child" data either in my opinion. While that 18 year old burglar's death might have been averted, the time period to intervene was years ago when the kid started down the wrong path. An intervention "now" which blames the homeowner for protecting her life, is misplaced to say the least.

Much as I want to reduce child deaths from violence, a 6 year-old child killed in a drive-by shooting is a victim of homicide - which is an awful, and heart-wrenching tragedy, not to mention a crime - but it has nothing at all to do with the firearms at home in "my" gunsafe - or the gunsafes of any of my neighbors.

One only has to look up the data on the CDC search engine for fatal and non-fatal injury statistics by age group and method of injury,

http://www.cdc.gov/injury/wisqars/fatal_injury_reports.html 
 

to see that most "actual" children are at much greater risk of injury and death from their swimming pools and automobiles than they are from firearms accidents. Yet, the AAP does not advocate for the removal of automobiles or swimming pools from the home and community, as they do for firearms. Why is that? This is only my conjecture, but I believe it is because many in the medical community do not acknowledge a legitimate purpose for firearms as they do for automobiles and swimming pools. I believe that they perceive firearms as an "evil" in and of themselves, which if removed, solves the problem. But that view is simplistic and naive in my opinion. Not to mention that it represents bad public health science.

Murder and violence are acts of Human Will that come from within the individual - they aren't embedded within the fibers of the tool. A firearm is a machine which is designed to throw a projectile. Done. End of story. It is the Human Will which determines whether that machine is used to protect/defend life, to compete in a marksmanship contest, to control an animal population, to punch holes in cardboard, to put meat on the table ... or to commit a crime. Reducing "Gun Violence" - as the medical community purports to want to do by advocating disarmament - will not be achieved by targeting people and their inanimate objects who are not the problem and who will never be the problem. In fact, the government's own data show that while firearms ownership continues to rise, that rates of violent crime continue to fall.

http://www.bjs.gov/index.cfm?ty=pbdetail&iid=4616

http://www.pewsocialtrends.org/2013/05/07/gun-homicide-rate-down-49-since-1993-peak-public-unaware/

I will not confuse correlation with causation here, because I know better than that. But it should at least be observed that even if increased gun ownership can't be credited as the "cause" of falling crime, it seems common sense to admit that the data indicate that it may have had no effect at all, or at least has not made things worse.

The medical community should, in my opinion, be aiming not at the "tool" - which does indeed have legitimate purpose even if they can't admit it - (and is a RIGHT guaranteed by the Constitution, to boot) - but at human behavior, at societal mores, and at cultural values. The problem for "us" as gun-owners is that it is easier to demonize an inanimate object (and the people associated with it) than it is to change human behavior.

As for me, being a physician and also member of my culture means that I tailor my firearms safety message to meet the needs of my community - not the dictates of my professional organization. I do recognize that every village has its idiot. No group is immune from the Yayhoos that makes us all look bad. So we do have to recognize that there are people who store and use their firearms unsafely, and we need to work - through education-  to make them as small a minority as possible.

That is why, when I have the time in an office visit (which isn't as often as I'd like), I talk to my little patients and parents about gun safety. Not disarmament - safety. I don't ask if there are firearms in the home, I simply assume that there are, and go from there. I ask "Does Janie or Johnny know what the rules are for the guns in the house?" I ask this with the same tone of voice and in the same conversation where I talk about bike helmets and seat belts. I have never had a bad reaction from a parent in this regard. I also talk about storage and the Eddie Eagle Rules.

If you see a gun:
STOP!
Don't Touch.
Leave the Area.
Tell an Adult.

And I reinforce with the kids that there is nothing wrong with learning to shoot and hunt - "Dr. LateBloomer shoots and hunts too", I say - but I want them to be safe and under adult supervision at all times.

I can do that because I have credibility with my patients. They know that I walk the talk. Obviously not every physician can do that without the appearance of political prying. Frankly, with position statements like the one cited above, who can blame patients and parents for being suspicious of such questions? If a physician does not understand the culture in which he or she practices, they risk alienating patients and losing not only personal trust, but credibility for the profession as a whole. Would "you" trust a physician who was working to take away your Constitutional right to vote? Or to exercise free speech? Or to freely assemble and associate? Well, for millions upon millions of gun families, it's the same darn thing.

It occurs to me that maybe in the interests of cross-cultural understanding, we should have a "Take Your Doctor to the Range Day". And no, I'm not going to head up that committee. Sorry folks - I'm just the idea gal - LOL.  But seriously, is that such a wild, outlandish idea? Maybe we in the firearms community "should" have more outreach aimed at the medical community. We docs have to have a certain number of hours of continuing education on a regular basis in order to renew our licenses and credentials - maybe someone (who is not me - Ha!) should come up with a CME module on Firearms Competence. How can you expect a doc who has zero experience with firearms, except what they see on the news and what their national governing body tells them, to have any competence (even with discussing safety) if they haven't had any training? It might go over like a lead balloon, but I think the idea at least bears some consideration.

I  also think it is very important for children to have "positive" firearms role models. That's another reason that I try to talk about it in the office visit. There is so much bad press out there about guns. We need to be good role models of safe practice - because kids often learn more by observing and example that they do by being lectured to. I only have them for a few minutes a year. You have them every single day of their lives. Be a good, safe example.

On the other side of that coin, we must admit, there are also a lot of "bad" examples going on in the movies and on TV and in video games. I think the firearms community needs to work on that. We need to reinforce with our kids that how such-and-such a detective on TV, or so-and-so action hero in the movies holds and uses their gun is NOT the proper way to do it in the real world with real guns. We also need to police our own ranks (see my "yayhoos" comment above). We need to educate each other, engage with each other, and work with each other. Our hobby/passion is already one of the safest out there, but we can still work on corralling and educating the less-safe ones. (And I said "educate" - not "legislate").

Now, having ripped the medical community about understanding gun culture, let's take a moment to talk about our OWN "cultural competence". If your doctor asks you questions you don't want to answer, please remember that he or she at least "thinks" they have your best interests at heart, and they are trying to do their job. Try to give them the benefit of the doubt. It might turn out to be a doc like me - who then turns the conversation to how deer season went,  how bad the ammo situation was this year, and did you see the latest Jerry Miculek video. If you don't trust your doc with that information, you don't have to be nasty. You can take the Fifth (I don't recommend drinking a Fifth - at least not in front of your doctor - Ha!); you can change the subject (Look! A Squirrel!); or you can just lie/obfuscate (What eees theeees "guns" that yoo speak of?).  Lord knows people lie to their doctors all the time about everything from diet to alcohol to sex. Why should guns be any different? (Please do not send nasty grams to my state board saying that I am encouraging lying - I'm being facetious here - people lie all the time with or without my encouragement. You KNOW you don't really eat 5 fruits and vegetable every single day. Personally, I think chocolate should be a vegetable, but I digress.)

We firearms enthusiasts also need to realize that though we are our own "culture", that this culture is not homogeneous. It isn't helpful if we split up into factions over "type" of gun or hobby. The last thing we need as a culture is to dissolve into infighting or apathy because "they're not after 'my' type of gun".  It also isn't always helpful to toss around political labels and epithets. We need the female gun owners, the gay gun owners, the gun owners of all races, the democrat gun owners, the independent gun owners, the duck hunters, the cops, and the doctors to be all under the same tent. Firearms owners and enthusiasts come in all shapes, sizes, religions, and political bents. You may even alienate a potential new range buddy (and thereby create a missed opportunity to swell our ranks) by tossing around labels that don't apply to everybody. Just something to think about...

So there you have it - my blather on culture. Take from it what you like, and toss the rest. It's my two cents and nothing more. I'm not going to make a habit of talking politics here, because I can't stand flame wars. I just want to have a nice, safe, happy little corner of the internet. So, in the words of Forrest Gump, "That's all I have to say about that" :-)

Oh, and Happy New Year!

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