Firearm Injury Prevention: Practical Office Tips

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.

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