EXECUTIVE SUMMARY

Investigators from the Violence Prevention Research Program (VPRP) at the University of California, Davis have unveiled a new resource for clinicians to guide them in their discussions with patients about firearms violence. Called the “What You Can Do” initiative, developers are encouraging frontline clinicians to familiarize themselves with the risk factors for gun violence, provide counseling to appropriate patients on safe firearms practices, and to intervene when there is an imminent threat of harm. Hundreds of providers have committed to take these actions.

  • While mass shootings are highly publicized, experts note that scores of people lose their lives to gun violence in the United States every day, and that frontline clinicians are uniquely positioned to intervene with at-risk patients.
  • The “What You Can Do” website offers background on the epidemiology of firearms violence as well as a practical guide on how to identify risk factors, what the risk groups are, and what clinicians should think about when tailoring their approach for specific patients.
  • While there are some barriers to offering firearms counseling in the clinical setting, many providers mistakenly believe that it is illegal to raise the subject with patients. However, experts say this belief is false.

With yet another mass shooting, and another emergency response — this time at a high school in Santa Fe, TX — clinicians are once again heralded for valiantly working to save the lives of the wounded. But that is small comfort to the families of the 10 people who were killed in the incident. It is dispiriting, to the say the least, to be confronted yet again with this distinctly American problem.

Further, while mass shootings make it to the front page, and are horrifying in their scope, gun violence is taking many more lives than what these highly publicized incidents suggest, with scores of people losing their lives to firearms in the United States on a daily basis. Indeed, one way or another, frontline clinicians deal with the issue every day, and many are asking whether there is something more they can do.

Certainly, hard data in this area are relatively scant, but the Violence Prevention Research Program (VPRP) at the University of California (UC), Davis maintains that clinicians can and should intervene with patients to prevent firearms violence. Program leaders have created the “What You Can Do” initiative aimed at arming clinicians with the knowledge and tools to do just that. (Editor’s Note: Learn more about the program by visiting: https://bit.ly/2kCFEh1.) While convincing overburdened practitioners to take on an additional responsibility almost always is a hard sell, hundreds have pledged to engage with patients who are at risk of harm from gun violence.

Make a Commitment?

While healthcare providers have been concerned about the gun violence epidemic for years, the genesis of the “What You Can Do” initiative can be traced back to an editorial published in the Annals of Internal Medicine in December 2017.1 It followed the mass shooting that took place in Las Vegas two months earlier, leaving 58 people dead and more than 800 wounded. (Editor’s Note: To read more about how local emergency responders handled this tragedy, please visit: https://bit.ly/2JnmtpG.) Garen Wintemute, MD, MPH, an attending physician in the ED at UC Davis Medical Center and director of the UC Davis VPRP in Sacramento has written numerous commentaries subsequent to other mass shootings, but wanted to do something more proactive this time. Consequently, in his resulting editorial, Wintemute forcefully made the case that that there are steps clinicians can take to make a critical difference on this issue.

In particular, Wintemute wrote that providers must take the initiative to ask appropriate patients about firearms and provide counseling on safe firearms behaviors. Physicians should take further action in cases in which they suspect there is an imminent threat of potential harm, he explained. Wintemute went one step further in his commentary, asking physicians to make a public commitment that they will, in fact, take these actions to address gun violence.

“Physicians understand that the way to change a patient’s health behavior is to have them make a public commitment, and that is exactly the principle we applied here,” Wintemute observes in a conversation with ED Management. “We asked physicians to make a public commitment, and Annals set up a process for them to do that ... and [the publication] has kept it up [on the website].” (Editor’s Note: The commitment is available at: https://bit.ly/2LNytih.)

Since the editorial was published, hundreds of physicians from all different specialties have committed to speak with patients about firearms and to offer counseling, and Wintemute notes that the reception to his recommendations has been mostly positive among clinicians.

“There are minor differences among us about when it is appropriate [to speak with patients about firearms], but there is no one who thinks it shouldn’t be done,” he says. “It is obviously the right thing to do under certain circumstances. We just don’t do a very good job of it.”

Leverage Resources

In fact, requests for tools and information on how to intervene with patients on this issue have been pouring in to the UC Davis VPRP.

“The providers who make the commitment have given us some feedback, and we’ve solicited feedback about what materials they need from us, what they need to study up on in order to be able to discuss firearms with their patients, and what sorts of barriers exist,” explains Rocco Pallin, MPH, a research analyst with the VPRP. Pallin notes that the most common request from providers is for more information on identifying patients at risk for firearms violence and how to counsel these patients. Additionally, providers want relevant materials that they can send home with patients. Pallin notes that the “What You Can Do” website is designed to address at least some of these requests.

For example, the website offers background on the epidemiology of firearms violence as well as a practical guide on how to identify risk factors, what the risk groups are, and what clinicians should think about when tailoring their approach for specific patients. There also are potential questions that clinicians can use to begin such conversations with patients.

“We give some detail about following up, what you might do in extreme risk situations, and where you can look for the laws that exist in your state regarding firearms,” Pallin shares. “The project really is a response to [Wintemute’s editorial], and with it we are trying to provide a practical tool that clinicians can use in the exam room with patients.”

UC Davis researchers see the project as a dynamic process that will evolve as clinicians continue providing feedback and more research is developed.

“We want to know what barriers come up and what additional challenges there are,” Pallin says. “We want to be able to adapt so that we are being most supportive.”

Establish Relevance

Wintemute acknowledges that he hears clinicians talk about perceived barriers to providing this type of counseling all the time. Many clinicians say they don’t have the time to speak with patients about firearms, while other clinicians claim they don’t have the knowledge or expertise to go down this road and aren’t sure how to intervene.

“The answers can vary from state to state, so it can require some investigating to find out what is legally allowed in a particular state,” Wintemute explains.

However, Wintemute maintains that discussing firearms with patients doesn’t require as much time as clinicians may think. For example, he notes that he doesn’t bring up the topic of firearms routinely. Rather, he first establishes whether questions in this area are relevant to the care of the patient.

“I am mindful of why the person is there. Maybe they are there because of an act of violence, which is a risk factor for future violence,” he says. “I will ask about risk factors [for future violence] like alcohol abuse, other controlled substance abuse, a prior history of violence, or recurrent visits for injuries.” If such risk factors are present, then Wintemute focuses on the issue of access to the means for doing harm.

“I ask some follow-up questions that might have to do with how much we need to be concerned about violence, and one of those questions concerns firearms, so I have established relevance with the patient and hopefully a good rapport along the way,” he observes. “I might then ask whether the patient has access to firearms or whether there are firearms in the home, or there may be a different question that is more pertinent to the particular situation.”

If a patient responds that he or she does have access to firearms, the follow-up will hinge on why Wintemute brought up the subject in the first place. For example, if he is concerned that the risk of violence or harm is very high and imminent, he will state that the patient’s access to firearms is concerning, and then solicit the patient’s response. “If the patient agrees, then maybe we can jointly come up with a plan for risk reduction,” Wintemute notes. “The specifics of that plan would vary from one patient to another, [based in part on] the patient’s family and circle of friends and also state law.”

Wintemute says that in some communities, depending on the laws regarding this issue, there are gun dealers who are willing to take firearms on a temporary basis during a crisis, and clinicians should know who those gun dealers are.

“Here in California, we have something called a gun violence restraining order where if I think the risk is really high, and I can’t persuade the patient to do something voluntarily, I can go to law enforcement or persuade the patient’s family to go to a judge,” he says. “Just like with domestic violence, if people make a good enough case, they can get a restraining order from a judge that leads to the firearms being recovered temporarily ... until the crisis blows over or treatment is put into place or until information makes it clear that extending the order is not necessary.”

Wintemute observes that it is not always the patient’s access to firearms he is most concerned about.

“I might be seeing a woman who is in a violent relationship, and it might be her partner’s firearms that I am concerned about for her sake,” he says. “Here in California, if even a temporary domestic violence restraining order is issued, and firearms are part of the picture, those firearms must be surrendered within 24 hours. That is the law, but the avenues open to physicians vary from state to state.” If such conversations seem too involved or uncomfortable, recognize that they get easier and faster with more experience, Wintemute stresses. “You get more flexibility and confidence in your ability to handle the answers to the questions [you pose about firearms],” he says. “And you get a better sense of what the local resources might be.”

Wintemute looks forward to the day when there are standards of practice on how to conduct such conversations, but in the meantime, he recommends that ED leaders interested in developing their approach to the issue of firearms violence engage in a group discussion about the issue, invite an expert to present best practices, and see if there is an agreement on how to proceed. “In academic settings, there could be grand rounds about this. We have done that here,” he offers.

Further, Wintemute notes that the VPRP is developing an instructional video for providers that will eventually be available to be shown at clinician gatherings. “Most physicians think they ought to do this. They may perceive one or more barriers, most of which are either [less significant] than they are thought to be or don’t even exist,” he says.

For example, Wintemute notes that some physicians believe it is illegal to engage in discussions about firearms with patients, but he notes that isn’t true. In fact, he has heard this concern so often that he authored an article on the subject in an effort to eliminate this false belief as a barrier to engaging patients on the issue.2

“[Clinicians] just need to talk amongst themselves and build up some collective willingness to start doing something that is the right thing to do,” he says. “No one is particularly comfortable with this, but that comfort will grow quite quickly.”

While Wintemute has counseled scores of patients about firearms, one case that stands out to him involved a woman who was in the hospital for treatment of a connective tissue disorder.

“She was obviously depressed ... so I started to ask a couple of questions, and the answers to those first questions led to a formal lethality assessment,” he recalls.

It turned out that the woman was a widow, and her husband had been a police officer, Wintemute shares. “The night before, in despair over her pain and worsening disease, she had taken his service weapon from the nightstand drawer, cocked it, and put it to her head, but she changed her mind, put it down, picked up the phone, and called 911,” he says. “So, here we are the next morning talking about it, but the gun is still in her home.” Fortunately, in this case, the woman did not fire the weapon, but decisions around access to firearms can be that critical. “People may be intoxicated or they may have had a lot of acute life change that is not for the better, and, temporarily, they are capable of making really bad decisions,” Wintemute notes. “But if it is temporary, and if the firearms can be removed for a short period of time, that allows for an intervention to be designed and implemented, and for the patients to receive it.”

Why should healthcare providers feel compelled to tackle this issue when they have so many other issues to be concerned about? Pallin notes that providers are in a unique position because they are screening patients for other health risks already. “We see that clinicians have an advantage there, and, additionally, we hope that the use of firearms conversations is happening when possible within established relationships,” she says. “What that would also mean is that there would be opportunities to follow up with patients about whether or not they were able to take the recommendations of the provider.” Nonetheless, while such opportunities are not always available to emergency providers, clinicians working in emergency settings are in a prime position to identify patients with certain individual-level risk factors for firearms violence. These include patients:

  • who present with violent injuries or unintentional, accidental injuries;
  • with a history of violent behavior or of violent victimization;
  • with drug or alcohol use disorders;
  • who exhibit impaired cognition or dementia;
  • with a history of abusive partners.

While there has been some research into the efficacy or impact of physician counseling on firearms violence, investigators note there is a need for much more work in this area.3 However, the prospects for new data have brightened considerably in light of Kaiser Permanente’s recently announced infusion of $2 million toward research in this field that will involve physicians and other professionals based at Kaiser’s hospitals and healthcare centers across the country. (Editor’s Note: Learn more about this initiative at: https://k-p.li/2GJ4qd0.)

Noting that its physicians and nurses have treated more than 11,000 gunshot wounds in 2016 and 2017, Kaiser states that it is hopeful that other healthcare organizations will make similar financial commitments to this issue in the coming months. However, researchers in the gun violence arena note that the Kaiser funding is highly significant, given the health system’s access to resources and its institutional ability to gather and report data. Wintemute observes there aren’t many healthcare systems with the size and scope of Kaiser, and he is hopeful that the work that will take place there will lead to evidence-based standards or guidelines on how clinicians can most effectively intervene with patients on firearms violence. Pallin adds that the VPRP looks forward to integrating any new findings into the “What You Can Do” website for clinicians to use.

“We’ve put this material together with the help of experts in firearms violence research and also clinicians who are interacting with patients, and we have really tailored it to their experiences and needs that they have expressed,” she says. “But that is because we can’t really wait for the science and the data that we need to really develop the best evidence-based approach — something that we can prove really works.”

However, Pallin notes that with Kaiser’s unique ability to implement and evaluate strategies for preventing firearms violence, investigators hopefully will be able to develop evidence-based curricula.

“That will be really important for this type of prevention strategy going forward as new providers are trained in firearms violence prevention,” she says. “What we are trying to do is make a resource that is useful for a variety of specialties, a variety of patient populations, and a variety of states.”

REFERENCES

  1. Wintemute GJ. What you can do to stop firearm violence. Ann Intern Med 2017;167:886-887.
  2. Wintemute GJ, Betz ME, Ranney ML. Yes, you can: Physicians, patients, and firearms. Ann Intern Med 2016;165:205-213.
  3. Roszko PJ, Ameli J, Carter PM, et al. Clinician attitudes, screening practices, and interventions to reduce firearm-related injury. Epidemiol Rev 2016;38:87-110.

SOURCES

  • Rocco Pallin, MPH, Data Analyst, Violence Prevention Research Program, University of California, Davis, Sacramento, CA. Email: rspallin@ucdavis.edu.
  • Garen Wintemute, MD, MPH, Attending Physician, Emergency Department, University of California, Davis Medical Center; Director, Violence Prevention Research Program, University of California, Davis, Sacramento, CA. Email: gjwintemute@ucdavis.edu.