Case Scenario
O.C., my 14-year-old patient, presents for a preparticipation sports examination before his high school volleyball season starts in several weeks. I care for his entire family, including his 8-year-old sibling, mother, and father. O.C.'s older brother is also my patient but no longer lives at home. O.C. shares that he has no physical or mental health concerns. My screening includes the American Academy of Pediatrics Bright Futures Questionnaire, and his mother lists that the family has firearms in the home. When I ask O.C. and his mother about her response, they share that the patient and his older brother own several hunting rifles. They state the rifles are stored without trigger or cable locks in an unlocked gun cabinet.
Commentary
Family physicians are well suited to engage in patient-centered discussions that promote firearm injury prevention. In 2018, the American Academy of Family Physicians published a position paper on the prevention of gun violence, recommending that family physicians ask patients about firearms in their homes; with patients who do own firearms, physicians are encouraged to discuss the safe storage of firearms and ammunition.1 A 2020 survey of more than 1,000 primary care physicians in North America showed that most who were surveyed were comfortable asking their patients about firearms; however, less than 8% were comfortable counseling them on firearm safety.2 This commentary is intended to serve as a framework for how physicians can translate the American Academy of Family Physicians call to action into clinical practice.
CLINICAL CONSIDERATIONS
Legality, medical ethics. Some clinicians may have concerns about the legality and medical ethics of screening for firearm possession and storage practices.3 In the United States, no federal or state laws explicitly prohibit physicians from asking patients about gun ownership or discussing firearm safety. From 2011 to 2015, several states enacted laws restricting or regulating such inquiries to protect patients' privacy (e.g., Missouri) and to prevent data collection on gun ownership (e.g., Minnesota, Montana).3,4 In 2011, the most restrictive of these physician gag laws passed in Florida, but it was overturned in 2017 after a court found it violated physicians' First Amendment rights.5
Patient reactions. Viewing firearm injury prevention as a clinical intervention through the lens of clinical ethics shows that this subject is within the scope of practice of a family physician. Counseling prevents harm by modifying conditions that have the potential to cause harm. It should be provided in a manner that is acceptable and does not harm the patient, promotes autonomy through respectful informational exchange, and aligns with the principle of distributive justice. Nevertheless, clinicians may be uncertain about how to initiate such conversations, worry that patients may be offended, or fear reprisal. Some patients may be hesitant to disclose firearm ownership. Research shows that when the rationale supporting screening for the risk of firearm-related injury is shared, many patients willingly engage in a dialogue around safe storage.6,7
SAFETY
In the United States, approximately 42% of households possess firearms.8 A national survey suggests that more than one-half of firearm owners do not safely store every firearm they own.9 Thus, as of September 2023, an estimated 4.6 million U.S. children reside in a home with a loaded, unsecured firearm.10,11
Firearm-related injury is the leading cause of death among those 1 to 17 years and younger, and 90% of child and adolescent firearm-related suicides were completed with a firearm owned by a family member. Considering this, family physicians have a significant role in screening and counseling patients and families on firearm injury prevention and safe storage.11,12
AT-RISK POPULATIONS
Screening for the risk of firearm injury should be performed for those living in homes with children, older adults, individuals with mental health conditions that increase the risk for suicide or homicide, those at risk for intimate partner violence, and military veterans. Given the prevalence of firearms in U.S. homes, clinicians may want to employ universal screening during preventive health visits.13 Statistical modeling forecasts that if just 20% of homes that do not currently have safe storage of all firearms implemented safe storage strategies within the home, 323 youth firearm shootings would be avoided, and 135 youth deaths from firearms would be prevented annually.14 This demonstrates that even with limited behavioral change, safely storing firearms can have an influential effect.
DISCUSSION
Set a respectful tone. Key elements of successful screening include maintaining a conversational and nonjudgmental tone while respecting the patient's knowledge of firearms.6 Because of the potentially politicized nature of discussing firearms, physicians may want to reflect on their personal beliefs around firearms before inquiring about the presence of firearms in a patient's home. Most firearm owners take injury prevention seriously. Leveraging this common point of concern may prove helpful for clinicians during firearm injury screening.
Language matters. Physicians should consider using more neutral terms (e.g., firearm rather than gun) because some words may carry unintended connotations.15 When discussing storage, the focus should be on firearm responsibility and prevention of unauthorized access rather than the use of language that may come across as limiting an individual's right to own firearms. Learning why a patient owns firearms (e.g., hunting, sport, personal protection) may provide a natural starting point for discussion while also guiding specific recommendations for safe storage or staging of firearms.
Examples of how to initiate this conversation could include asking about firearm access as a standard part of the patient's social history (Table 1). Risk screening should include questions about the presence of firearms in any places visited by children, including the homes of friends and family members. Offering parents scripted questions and statements (e.g., “our family doc wants us to ask”) for various situations (e.g., before a playdate) may prove helpful.
TABLE 1. Sample Screening Questions for Patients About Firearm Accessibility
| Preliminary questions |
| “As we talk about injury prevention, I want to check in about any firearms you may have in your home. Are there firearms in your home?” |
| “Because of the risk of injury from firearms, I ask all my patients about access to firearms. Do you have access to firearms?” |
| If patient shares affirmative access to firearms, follow up with clarifying questions |
| “What is your plan to prevent unintended access to your firearms?” |
| “What is your plan to keep high-risk individuals (e.g., children, people with mental health disorders) from gaining access to your firearm(s)?” |
| “Do you have any concerns about your mental health that make you feel uncomfortable about your current access to firearms?” |
Be prepared to counsel patients on risk reduction and safe storage of firearms. The National Shooting Sports Foundation outlines the core principles of safe firearm storage in their Firearms Responsibility in the Home resource.16
- Firearms brought into a residence should be unloaded
- Firearms should be stored and secured with a locking device (e.g., trigger lock, cable lock, locking gun case, fire-armsafe; eTable A)
- Ammunition should be stored separately and locked up
eTABLE A Firearm Storage Options
| Type | Description | Price ($) | Beneficial features |
|---|---|---|---|
| Cable lock | Can be used on most firearms Allows for quick access in an emergency Cable runs through the barrel or action of the firearm to prevent it from being accidentally fired; requires a key or combination to unlock | 10 to 30 | Accessible Affordable Theft deterrent |
| Gun case | Option for concealing, protecting, or legally transporting a registered firearm Available in a variety of materials (e.g., plastic, fabric, metal) Must be locked with an external device | 10 to 150 | Affordable Portable Protects from damage |
| Lock box | Reliable protection with integrated locks Option for legally transporting outside of the home | 20 to 150 | Accessible Portable Protects from damage |
| Electronic lock box | Effective way to store or legally transport firearms Some are specially designed for quick access to stored firearms | 50 to 200 | Portable Protects from damage Theft deterrent |
| Full-size and biometric gun safes | Protect from the elements Allow storage of multiple firearms in one place Available in many sizes Many have biometric options | 200 to 2,500+ | Protects from damage Theft deterrent |
Information from National Shooting Sports Foundation. Gun storage for your lifestyle. June 5, 2013. Accessed April 2, 2024. https://www.nssf.org/articles/infographic-a-range-of-gun-storage-options-for-your-lifestyle/
Children should be instructed to never touch firearms unsupervised and to immediately find a trusted adult should they encounter an unsecured firearm.17 Clinicians should also underscore that simply storing firearms out of sight or telling children not to touch a firearm is insufficient for injury prevention.
The most common reason patients say they own a firearm is for self-protection (88%); thus, the goal for many of these patients may be safe staging of the firearm with ammunition available.10 One staging option is placing the firearm in a lock box easily accessed with a biometric scan, fob, or confidential punch code. To reduce the risk for personal injury, the firearm chamber should be clear with the loaded magazine removed and placed next to the firearm within the safe-storage device.
When patients believe that in-home storage is inappropriate because of concerns about access by or injury to a child, another family member, or even themselves during a time of mental health crisis, offsite storage of firearms is a viable option. This includes voluntary temporary transfer of firearms to a loved one or to a local gun shop that offers firearm storage.
For patients who disclose access to unsecured firearms, physicians may elect to provide the patient with a safe-storage device. Many health systems have trigger or cable locks available for distribution to patients. Receiving locking devices in real time and free of charge has proved to be the most effective intervention to influence safe storage by patients.18 Based on a patient's needs and preferences, the clinician may refer the patient to a local expert, such as a gun shop, for purchase of a lock box or gun safe. In addition, collaboration with gun shops allows clinicians to refer patients for training, such as safety or certification classes to reinforce the principles of safe firearm operation and storage to further reduce the risk for firearm injury.
Case Resolution
Unprompted, O.C. and his mother share that they should better secure the family's rifles. Discussion points for this visit should focus on storage options, including trigger and cable locks and gun safes. If your clinic stocks trigger and cable locks, you can show these in the examination room, giving the patient the option to select a locking device for each rifle. If O.C.'s mother expresses a preference for a gun safe, one option is to provide her with the contact information for a local gun shop that sells safes and to encourage her to discuss purchasing a gun safe with her partner so that the entire family is on the same page. Consider checking in with the parent during their own future visits about their progress in safe firearm storage. If they share that storage solutions have been enacted, make a note for O.C.'s next visit to tell him you are proud of him for being a responsible sportsman and then check in on how storage options are working for him and his family.
The authors thank Steve D’Orazio, owner of Max Creek Outdoors, Oregon, Wis., and President of the Oregon Sportsman’s Club, Oregon, Wis., for his partnership and passion for firearm injury prevention education. We also thank our friends Jean Papalia, Leah Rolando, and Tom DuVal at Safe Communities Madison-Dane County, Madison, Wis., for their ongoing work to reduce firearm injuries in our community.
