You Will Shoot Your Eye Out

Aman comes to Northwell Health’s hospital on Staten Island with a sprained ankle. Any allergies? the doctor asks. How many alcoholic drinks do you have each week? Do you have access to firearms inside or outside the home? When the patient answers yes to that last question, someone from his care team explains that locking up the firearm can make his home safer. She offers him a gun lock and a pamphlet with information on secure storage and firearm-safety classes. And all of this happens during the visit about his ankle.

Northwell Health is part of a growing movement of health-care providers that want to talk with patients about guns like they would diet, exercise, or sex—treating firearm injury as a public-health issue. In the past few years, the White House has declared firearm injury an epidemic, and the CDC and National Institutes of Health have begun offering grants for prevention research. Meanwhile, dozens of medical societies agree that gun injury is a public-health crisis and that health-care providers have to help stop it.

Asking patients about access to firearms and counseling them toward responsible storage could be one part of that. “It’s the same way that we encourage people to wear seat belts and not drive while intoxicated, to exercise,” Emmy Betz, an emergency-medicine physician and the director of the University of Colorado’s Firearm Injury Prevention Initiative, told me. An unsecured gun could be accessible to a child, someone with dementia, or a person with violent intent—and may increase the chance of suicide or accidental injury in the home. Securely storing a gun is fundamental to the National Rifle Association’s safety rules, but as of 2016, only about half of firearm owners reported doing so for all of their guns.

Some evidence shows that when health-care workers counsel patients and give them a locking device, it leads to safer storage habits. Doctors are now trying to figure out the best way to broach the conversation. Physicians talk about sex, drugs, and even (if your earbuds are too loud) rock and roll. But to many firearm owners, guns are different.

Not so long ago, powerful physicians argued that if guns were causing so much harm, people should just quit them. In the 1990s, the director of the CDC’s injury center said that a public-health approach to firearm injury would mean rebranding guns as a dangerous vice, like cigarettes. “It used to be that smoking was a glamor symbol—cool, sexy, macho,” he told The New York Times in 1994. “Now it is dirty, deadly—and banned.” In the 2010s, the American Academy of Pediatrics’ advice was to “NEVER” have a gun in the home, because the presence of one increased a child’s risk of suicide or injury so greatly. (“Do not purchase a gun,” the group warned bluntly.) And when asked in 2016 whom they would go to for safe-storage advice, firearm owners ranked physicians second to last, above only celebrities.

That year, in California, Barnhorst launched the state-funded BulletPoints Project, a free curriculum that teaches health-care workers how and when to talk about firearms with their patients. The program instructs them to keep politics and personal opinions out of the conversation, and to ask only those patients who have particular reasons for extra caution—including people with children, those experiencing domestic violence, or those living with someone with a cognitive impairment. It also suggests more realistic advice than “Do not purchase a gun.” Maybe a patient has a firearm for self-defense (the most common reason to have one), so they’d balk at the idea of storing a gun unloaded and locked, with the ammunition separate. A health-care worker might recommend a quick-access lockbox instead.

Researchers are now testing whether these firearm conversations have the best outcome if doctors broach them only when there’s a clear reason or if they do it with every patient. Johns Hopkins is trialing a targeted approach, talking about firearms and offering gun locks in cases where pediatric patients have traumatic injuries.

Meanwhile, Northwell Health, which is New York State’s largest health system, asks everyone who comes into select ERs about gun access and offers locks to those who might need them. Both of these efforts are federally funded studies testing whether doctors feel confident enough to actually talk with patients about this, and whether those conversations lead people to store their firearms more securely.

For doctors, universal screening means “there’s no decision point of who you’re going to ask or when you’re going to ask,” Sandeep Kapoor, an assistant professor of emergency medicine who is helping implement the program at Northwell Health, told me.

So far, Northwell’s trial has screened about 45,000 patients, which signals that the approach can be scaled up. Kapoor told me that with this strategy, gun-safety conversations could eventually become as routine for patients as having their blood pressure taken. When she was in primary pediatrics, Katherine Hoops, a core faculty member at Johns Hopkins’s Center for Gun Violence Solutions, worked firearm safety into every checkup, as she would bike helmets and seat belts.

(The American Academy of Pediatrics still maintains that the safest home for a child is one without a gun, but the organization now recommends that pediatricians talk about secure storage with every family, and offers a curriculum on how to have this conversation.)

Universal screening can also find people whom a targeted approach might miss: The team at Northwell recently learned through screening questions that a 13-year-old who came in with appendicitis had been threatened with guns by bullies, and brought in his parents, a team of social workers, and the school to help.

But a patient in the ER for a sprained ankle may understandably wonder why a doctor is asking about firearms. “There’s no context,” Chris Barsotti, an emergency-medicine physician and a co-founder of the American Foundation for Firearm Injury Reduction in Medicine, told me. The firearm community, he said, remembers when “the CDC wanted to stigmatize gun ownership,” so any movement for health care workers to raise these questions needs nuance. To his mind, these should be tailored conversations.

Betz, of the University of Colorado, raises the question only when a patient is at risk, and believes that firearm safety can otherwise be in the background of a practice—for example, in a waiting room where secure-storage brochures are displayed alongside pamphlets on safe sex and posters on diabetes prevention.

About half of firearm-owning patients agree that it’s sometimes appropriate for a doctor to talk with them about firearms, according to a 2016 study by Betz and her colleagues. They’re even more okay with it if they have a child at home. The physicians I asked said that the majority of the time, these conversations go smoothly.

But Betz’s study also found that 45 percent of firearm-owning patients thought doctors should never bring up guns. Paul Hsieh, a radiologist and a co-founder of the group Freedom and Individual Rights in Medicine, wrote in an email that gun owners he’s spoken with “find the question about firearms ownership intrusive in a different way than questions about substance use or sexual partners.”

Chethan Sathya, a pediatric trauma surgeon and the director of Northwell Health’s Center for Gun Violence Prevention, pointed out that those topics used to be contentious for physicians to talk about. To treat guns as a public-health issue, “we can’t be uncomfortable having conversations,” he told me.

But doctors have more power in this situation than they do in others. They might tell someone with diabetes to stop having soda three times a day, but they can’t literally take soda away from a patient. With guns, they might be able to. In states with extreme-risk laws, if a health-care provider believes that their patient poses an immediate threat to themselves or others, they can work with law enforcement to petition the court to temporarily remove someone’s firearms; a handful of states allow medical professionals to file these petitions directly. There are many people “across America right now who own guns and won’t come to counseling, because they don’t want their rights taken away for real or imagined reasons,” Jake Wiskerchen, a mental-health counselor in Nevada who advocates for such patients, told me. They worry that if their doctor includes gun-ownership status in their medical record, they could be added to a hypothetical national registry of firearm owners. And if questions about guns were to become truly routine in a doctor’s office—such as on an intake form—he said owners might just lie or decide they “don’t want to go to the doctor anymore.”

Physicians accordingly choose their words carefully. They talk about preventing firearm injury instead of gun violence—both because the majority of gun deaths are suicides, not homicides, and because it’s a less loaded term. Telling a diabetic patient to cut back on soda might work, but people “are not just going to throw their guns in the trash,” Barnhorst, of UC Davis, told me. “There’s a lot more psychological meaning behind firearms for people than there is for sodas.”

Barsotti says a public-health approach to firearm safety requires more engagement with the upwards of 30 percent of American adults who own a firearm. Owners of shooting ranges and gun shops are already “practicing public health without the benefit of medical or public-health expertise,” he told me. They’re running their own storage programs for community members who don’t want their guns around for whatever reason; they’re bringing their friends for mental-health treatment when they might be at risk. Betz’s team collaborated with gun shops, shooting ranges, and law-enforcement agencies in Colorado to create a firearms-storage map of sites willing to hold guns temporarily, and she counsels gun clubs on suicide prevention, as a co-founder of the Colorado Firearm Safety Coalition. Exam-room conversations can be lifesaving, but in curbing gun injury, Betz told me, health-care workers “have one role to play. We’re not the solution.”