Monday, February 23, 2015

Universal Precautions for Gun Safety?

With the advent of the Electronic Medical Record (EMR), which is being pushed with the carrot and stick approach by Medicare and Medicaid, there has been a bigger push lately to "document" firearms ownership in a patient's medical record. My reservations about EMR aside (drunken monkeys on unicycles could write more useful software than this), I am bothered by this trend. I am bothered by the prospect of the federal government, via Medicare and Medicaid, mandating what kinds of questions must be asked of patients (and therefore what data is collected - because the government never met a piece of data that it didn't like to "use" in some way for good or ill). Asking about firearms - because of the Constitutional/Civil Rights implications - carries much more baggage than asking about other "lifestyle" issues.

Conversely, I am also bothered by the prospect of the law "muzzling" physicians during their patient interactions. Sometimes you have to ask the hard questions. But that should be for "me" as a physician to decide - not the government.  I also realize that just because I ask a question doesn't mean that I get a truthful response. People lie to their doctors all the time - from "Yes, I always eat 5 fruits and veggies a day", to " No, I have no idea how my infant got a broken femur". So, just because I ask, doesn't mean that I gain useful information from the exchange - even about firearms. This is just a natural fact of healthcare.

With all of the ongoing struggle about healthcare providers asking about guns, it occured to me that nobody is getting to the root of the issue. It occcured to me how inconsistent this approach really is with how we practice the REST of healthcare.

Why "ask" patients if they own guns? Why not just counsel EVERYONE? If the healthcare powers-that-be are genuinely interested in "safety", and not targeting the constitutional rights of patients, then they shouldn't need to ask.  One does not have to be in actual possession of a firearm in order to benefit from basic safety counseling. This is why Eddie Eagle and similar programs are given to entire classrooms of children - because a child could encounter a firearm at other locations besides home. How many grown adults could also benefit from this type of safety counseling? How many wives don't have a clue about their husbands' firearms? How about mothers coming across their son's drug stash along with his illegal pistol? Teaching basic safety  - especially what constitutes safe storage, and what NOT to do when one comes across a firearm - could be beneficial to an entire patient population - not just the ones who admit to owning firearms.

Personally, I try to talk about proper storage and the Eddie Eagle Rules to all my families during the yearly well visit. I don't always get to everyone because of time limitations and what all else we have to talk about, but I do try. I don't record anything in the medical record either. This falls into the same conversation I have about seatbelts, bike helmets, pool safety, and the Poison Control number. And I don't ask if there are guns in the home, I ask if the kids know what the safety rules are for any firearms they may encounter.

I hate to admit this, but I am old enough to remember the days before "Universal Precautions" came into play in healthcare. In those bad old days when I worked in the lab, we didn't wear gloves to handle blood and body fluids unless the specimen had a sticker on it that said "hepatitis" or the like (this was before HIV - yes, I'm that old). The fatal flaw in that policy was that it wasn't the cases that you KNEW about that could hurt you, it was the ones that were infected, but not yet diagnosed that you could be exposed to while handling the specimens. Thus, when HIV showed up, Universal Precautions became a thing - treating EVERYONE as if they could be potentially infectious.

This is the "common sense" universal counseling approach we should be using for firearms safety, IMO. Because EVERYONE could potentially at some point come across an unsecured firearm. And this approach is consistent with other safety counseling that we give to parents and children. We don't counsel about safe sex ONLY to those who admit to being sexually active, do we? We don't ONLY counsel about tobacco and alcohol to those kids who admit to using them, do we? We don't ONLY counsel about pool/swimming safety to those who admit to owning backyard pools, do we?

Some folks may argue that asking about firearms targets "gun violence", and provides "red safety flags".  Well, if we are actually looking for "red safety flags" as is purported, why don't we ask patients if they have a baseball bat in their house (assault data)? Why don't we ask if they keep long lengths of rope in their home or if they know how to tie a noose (suicide data)? And why don't we ask if there are tall bridges in their neighborhood or long kitchen knives in their drawers? Yet we ask about Firearms in total isolation. It's inconsistent.

IF we are genuinely concerned about firearms "safety", what we SHOULD be doing is discussing gun safety with everyone universally, whether they admit to owning one or not. That way you avoid potentially unconstitutional questions, and you educate people who might not even KNOW there is a gun in the house. Granted, most healthcare professionals don't have a clue how to talk about basic firearm safety, but that's what NSSF pamphlets are for. I don't explain every nuance of booster seats - I give a brief talk and a pamphlet. That's how it works - at least if "safety" is genuinely the goal and not a ruse for political ends.

I think this simple change of approach would help ensure the goal of "gun safety" that the healthcare community purports to want, while not infringing upon the Constitutional rights of patients. The only box we as physicians should have to check on a form should say "Discussed Safety", NOT " Are there firearms in the home?" 

Do I REALLY think this will happen? - Nope. But at the very least, this approach might help to expose the real agenda.


  1. YES!!!! So much yes! I love this approach. I'm totally sharing this.

    (BTW, I, too, am old enough to remember patient handling without gloves and mouth pipetting :) )

  2. Ahh yes - mouth pipetting - *shudder* LOL

    And now the AAFP has declared that magazine capacity is a public health issue. The idiocy continues...