Garen Wintemute, gun violence researcher at UC Davis
Garen Wintemute, MD, MPH, (photo credit: Karin Higgins/UC Davis via ProPublica)

Long-time gun violence researcher, Garen Wintemute, MD, MPH, who runs the Violence Prevention Research Program at the UC Davis, and his emergency physician colleague from the University of Colorado, Marian Betz, MD, MPH, have written a very interesting opinion piece in the August 4, 2015 issue of JAMA. It’s titled, “Physician Counseling on Firearm Safety: A New Kind of Cultural Competence.”

In it, they call for physicians to learn how to personalize gun safety counseling based on their patients’, not their own, firearms beliefs and preferences. They say doing that starts with “developing cultural competence in firearm safety counseling.”

 

What is cultural competence?

The authors outline the components of cultural competence as follows:

  • Respect for variation among cultures
  • Awareness of your own beliefs and practices
  • Interest in learning about other cultures
  • Developing skills to enhance cross-cultural communication
  • Acknowledgement that culturally competent practices support delivery of quality health care

So why talk about cultural competence when talking about gun safety counseling? Are gun owners really that different from non-gun owners? When it comes to how the two groups view guns ownership, I think (but cannot prove) that there is a significant cultural difference. Just think of the last time you got into a discussion with someone from the opposite side of the gun ownership debate. If your experience is like mine, you would probably say you were talking past each other and not really engaging in a way where either of you could learn from the other, right?

Betz and Wintemute suggest that the “gun culture” is not homogeneous, rather “…perspectives and preferences may vary based on [the] reasons for owning firearms.”

 

Personalizing the message

Rather than having a one-size-fits-all message about gun safety built off your personal belief system, the authors suggest finding out what kind of guns the patient (or spouse) has and why they have them.

Pediatrician, mom and toddler
Photo credit: UW Health via Flickr creative commons

That way, instead of saying “You have kids, you need to get rid of all of your guns,” you could talk to Mom about the risk to her toddler if she keeps a handgun loose in her purse and then suggest some safe alternatives, such as a holster that covers the trigger guard.

If, for example, Dad only has long runs for hunting, he could be counseled to put them in a combination gun safe when they are not in use. Or, if he says he needs a handgun for personal protection, it might be helpful to suggest getting a fingerprint operated lock box.

If the context of the counseling is a risk of suicide, a discussion of the “clear link between firearm access and elevated risk of suicide because of the high lethality of firearm suicide attempts” may be the appropriate framing.

Obviously, I am not an expert in all the different types of guns and gun safety options—and I am certainly not interested in becoming one—but I would be willing to learn more about guns and gun-safety counseling from people more knowledgeable than myself. For example, as the authors suggest, from my gun-owning colleagues.

 

Physicians who own guns

Somewhere between 13% to 41% of physicians own firearms according to two papers cited in the article. And, importantly, the paper suggests, “physicians who own guns may be more likely than those who do not to counsel patients about firearm safety.” Rather than thinking, geez, what’s wrong with those crazy gun-packing doctors, the authors suggest these gun-owning physicians could play an important leadership role in developing cultural competence in firearm safety counseling. Now, that’s an interesting take.

 

Call to action

The paper closes by saying that “Physicians are entitled to their own perspectives and political opinions, but to serve patients and protect them from disease and injury, it is important to counsel them in ways that are respectful, meaningful, and effective.”

Of course, this is true and physicians have had to learn to do this related to many different health-related issues that they may have found challenging, such as counseling gay men to practice safe sex during the height of the HIV epidemic or talking to heroin addicts about needle exchange. I think physicians will step up to the plate and acquire the necessary skills if they think it will help.

I, myself, like what these authors have to say. And though I hope they are right, I am not yet completely convinced it will work. That being said, it is clear doctors need a different approach to firearm safety counseling than we, by and large, have employed in the past.

That’s my two cents, what’s yours?

8 COMMENTS

  1. Cultural competence is definitely an important part of talking about gun safety. Broaching the topic with parents that own firearms should be done so in a calm, open-minded manner, which can only follow from cultural competence. Thanks for sharing.

  2. I am not a doctor. I am however a federally licensed firearms manufacturer, have been competing since I was 14, and have been an instructor for 15 years.

    Lets agree that I won’t give out medical advice, and you all won’t give out firearms advice. OK?

    • Primary care docs’ job includes counseling to prevent preventable illness and injury. Firearms safety counseling clearly falls in that job description. However, I do think it is important that firearms dealers/manuracturers not give out medical advice…thanks for that!

      • First I appreciate you publishing my challenge. I did not expect it to make it through moderation. I appreciate civil discourse. Reasonable people can disagree. I hope that you allow this post past moderation.

        What qualifies doctors to conduct firearms safety counseling. (your words)? Do most doctors even know the 4 rules of firearm safety? I won’t let my students take the test basic pistol certification or actually shoot a firearm unless they can recite them to me.

        How many doctors actually know those basics? Owning, handling and shooting firearms safely is not something a doctor can pick up in a seminar. Just suggesting to a parent to “lock up your gun” is not going to help. Many people keep firearms for home defense. They need information on systems that will protect their firearms while still allow them easy access. Are doctors prepared to discuss the finer points of biometric locks vs keys, vs simplex locks? How about different safe storage methods for different firearms? I tell you this because if a Dr. just tells a gun owning parent to “lock it up”. It won’t do a thing, if the parent doesn’t know about all the options available and what works best in a given situation with a given firearm.

        Tell me, do doctors talk to patients about swimming pools? I ask because if this were truly apolitical, they would. Roughly 600 kids perish in accidental drownings in swimming pools every year. In contrast, about 70 kids die in actual shootings each year. So which is the bigger public health concern?

        What about household chemicals? Roughly 1700 kids die from accidental ingestion of household chemicals. I’m not trying to be an idiot, but the premise for this is always exactly what you said. Public health, public safety. Put the effort where the problem is largest and where it can do the most good. But if that were truly the case, doctors time would be better spent discussing greater risks like swimming pools and household chemicals.

        The reality is that the American Academy of Pediatrics, where a lot of this is coming from, is vehemently anti-gun. They have been for years.

        We all want the same things. I think a far better solution is that if parents volunteer that they are gun owners, the doctors refer them to an expert in firearms use and safety. Which is something that most doctors are not.

        I hope this discourse is appreciated. I strive to keep things civil. I thank you for the opportunity for my opinions to be heard.

        • I believe the authors of the Opinion Piece would agree with you. Primary Care doctors are not experts in everything they counsel patients about. Rather they rely on reputable, reliable, and hopefully non-biased resources that they can connect their patients with. If you look carefully at the original JAMA article, you will see they highlight a collaboration between medical folks and firearms folks as a way to reduce firearm injuries. We clearly need an approach that is different from the polarized discussions of the past.

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