As the epidemic of gun violence continues across the United States, an emerging effort to pass extreme risk protection order (ERPO) laws (also known as “red flag” or gun violence restraining order laws) in state legislatures across the country offers an opportunity to save lives. Already law in more than 10 states and under consideration by state legislatures in approximately 30 others, ERPO laws allow family or household members, law enforcement, and, less commonly, health care professionals to petition courts to temporarily remove access to firearms from people who are thought to pose an imminent risk to themselves or others.1,2 Given that these policies are being so widely considered, many current and future physicians may soon practice in a state where an ERPO is an available tool. These policies and other gun violence prevention measures rely, in part, on physicians to become competent in inquiring and counseling about firearm safety, to raise awareness among patients about the existence of relevant legal pathways, and to make informed assessments of a patient’s risk for violence and impulsivity. While ERPOs represent an important tool to prevent firearm-related injuries, physicians currently receive minimal firearm safety–related training and may be ill-equipped to make these types of risk assessments, preventing the benefits of these important legislative efforts from being fully realized.
The Gun Violence Epidemic in the United States
In 2017, more than 39,000 people died from gun violence in the United States.3 Thirty-seven percent of those deaths were the result of homicide (including mass shootings), approximately 1% were due to unintentional injuries, and the majority (approximately 60%) were due to suicide.4–6 The demographic disparities in this epidemic are stark. According to the Centers for Disease Control and Prevention (CDC), in 2016, non-Hispanic black men had a 15-fold increased risk and Hispanic men had a 3-fold increased risk of dying from homicide by firearm compared with non-Hispanic white men.7 In contrast, when examining suicide by firearm, non-Hispanic white men and non-Hispanic American Indian men were at the highest risk.7,8 In terms of both homicide and suicide by firearm, men died at a rate substantially higher than women.7
Further, suicide is becoming increasingly prevalent: Between 1999 and 2016, the suicide rate in the United States increased by 30% or more in half of all states.9 Given that firearm access is an independent risk factor for death from suicide, changing a person’s access to lethal means in potential periods of crisis may save lives.10–12 According to the CDC, more than half of those who died from suicide in 2015 had no known mental health condition.9 This underscores the importance of including not only mental health professionals but also internists, pediatricians, surgeons, obstetrician–gynecologists, and emergency medicine physicians in suicide and other violence prevention efforts.
The Potential of ERPOs
As one part of a multidisciplinary approach to address the national gun violence epidemic, ERPO laws offer a tool for concerned family or household members, law enforcement, and, in some cases, health care professionals. These laws were motivated by the deficiencies in existing mechanisms to prevent access to firearms for individuals known to pose a risk to themselves or others.13 The deficiencies in existing mechanisms include that they are often unclear, inconsistently operationalized, and difficult to navigate, explaining why the investigations of many gun-related deaths reveal missed opportunities to intervene in spite of clear warning signs. For example, according to media reports, in 2010, Jared Loughner was suspended from a community college for threatening behavior. His parents recognized this concerning behavior change and removed his shotgun, hid his car keys, and encouraged him to seek medical care.14 However, without evidence that he had committed a criminal act, options to prevent him from obtaining additional guns were limited, and his family, local police, and health care professionals were unable to collaborate effectively. With no mechanism in place to prevent it, Loughner ultimately purchased a handgun and used it to kill 6 people and seriously wound Congresswoman Gabrielle Giffords in Tucson, Arizona.15,16
While this case illustrates one example of how an ERPO may prevent homicide, the same strategy of temporarily restricting access to guns may also prevent suicide. The recognition that people who die from suicide often exhibit identifiable warning signs offers a chance to intervene.17 As described in a recently published case report, a 37-year-old man used 1 of his 4 guns, an AR-15, in a suicide attempt.18 The many risk factors he exhibited before this suicide attempt—escalating alcohol and other substance use, report of a domestic disturbance requiring a call to the police, and escalating stress at work—went unrecognized.18
ERPO laws attempt to streamline the process by which people who may pose an imminent risk can be kept from accessing firearms. The specific provisions of ERPO laws vary by state. For example, in Oregon19 and Massachusetts,20 physicians do not have an explicit role (i.e., a family or household member or law enforcement are required to be the petitioners); however, physicians may still have an important role to play in counseling on firearm safety and educating patients and families about the existence of this legal option. In contrast, the law in Maryland specifies physicians, social workers, and mental health nurses as primary petitioners, highlighting the salient role that legislators in that state envision for health care providers in tackling this issue.21
Evidence that ERPOs can save lives is growing. In 1999, Connecticut became the first state to pass such a risk-based gun removal policy. A systematic study of the 762 gun removals conducted in Connecticut between 1999 and 2013 used population-level gun-related fatality rates to estimate the number of additional suicide deaths that would have occurred if these individuals had retained access to their guns. The investigators concluded that 1 death from suicide was averted for every 10 to 20 firearm removals.22 A quasi-experimental design using state-level data demonstrated a 7.5% reduction in firearm-related suicides from 2005 to 2015 in Indiana after implementation of its version of an ERPO (called a firearm seizure) law.23 Several cases of successful interventions that prevented homicides in California as a result of these types of laws have also been reported, with a formal evaluation of the impact of the statute in that state currently ongoing.13
While the specific provisions of these laws vary by state, physicians must be able to assess risk and serve as a resource for patients or concerned family members who seek medical advice. The ability to assess risk in the context of firearm-related violence without compromising the patient–physician relationship and while maintaining compliance with the Health Insurance Portability and Accountability Act of 1996 is an important skill. Given that the nationwide movement toward ERPOs is underway and that gun violence prevention will require a comprehensive and multidisciplinary approach, the medical community must prepare trainees and practicing physicians to take on this charge.
Risk Assessment in Clinical Practice
Assessing risk is a core part of all medical practice. Standard history taking in conversations with patients includes screening for the use of alcohol, tobacco, and drugs as well as the use of seat belts, bike helmets, and carbon monoxide alarms because having a specific understanding of a patient’s risk factors leads to more appropriate counseling. In the context of ERPOs, risk assessments require an understanding of whether patients have access to firearms. Asking about firearms is not a paradigm shift in the patient–physician relationship but, rather, should be seen as a natural extension of these routine assessments about home and personal safety.
Notably, this issue of physicians asking patients about firearm ownership has been specifically challenged in the courts, most famously epitomized by the so-called “gag law” passed by the Florida legislature in 2011. This law, which prohibited physicians from routinely inquiring about patients’ firearm ownership, was challenged in court. Ultimately, most provisions of the law were struck down by the 11th Circuit Court of Appeals, affirming physicians’ right to inquire about firearms.24 In 2015, 7 physician professional societies—the American Academy of Family Physicians, American Academy of Pediatrics, American College of Emergency Physicians, American College of Obstetricians and Gynecologists, American College of Physicians, American College of Surgeons, and American Psychiatric Association— and 2 other professional societies released a joint statement specifically opposing restrictive laws that interfere in the patient–physician relationship.25 The American Academy of Pediatrics, in particular, urges pediatricians to identify and counsel parents who possess guns about safe firearm storage.26
Despite the broad agreement among medical professional societies that physicians have an important role to play in educating and counseling patients about firearm safety, only 12% of U.S. medical students report extensive training related to gun safety by their fourth year, and few clinicians incorporate such screenings into routine practice.27,28 Given the time constraints that often limit clinical encounters, physicians could prioritize discussions with potentially high-risk patients such as those with suicidal or homicidal ideation, a personal history of violence or substance use disorders, or dementia (an underrecognized population at elevated risk of gun-related injury).29 Betz and Wintemute, who consider having appropriate discussions about firearms with patients to be a new “cultural competence,” recommend that physicians maintain a nonjudgmental, open dialogue and provide information on safe storage options while discussing firearms with patients.30 Wintemute and colleagues suggest using the 5 Ls (locked, loaded, little children, feeling low, learned owner) as a framework to guide physicians in screening for risk factors for firearm-related violence.28
A Gap in Training
If physicians are to be effective partners in efforts to prevent gun violence, then they must have some baseline knowledge about firearms, such as how to safely store guns and how to counsel patients who own or have access to them. Unfortunately, evidence suggests the medical community is far from achieving even those basic competencies. In a systematic review of the published literature on training programs in undergraduate, graduate, and continuing medical education, Puttagunta and colleagues found only 4 training programs that included firearm safety trainings for health care providers.31 Their evaluations of the outcomes of these programs concluded that a significant need exists “to develop and evaluate teaching” in this area.31 At the graduate medical education level, almost a third of family medicine residency program directors reported their curricular emphasis on “violence generally” as “very little” or “none at all,” suggesting that the emphasis on firearm-related violence specifically would be even less.32 This lack of training exists at the attending physician level as well. In a survey of North Carolina physicians, only 65% of respondents reported knowing how to counsel patients about gun safety, and just 12% reported attending any continuing medical education training on gun violence in the last 5 years.33 Similarly, Price and colleagues found that only 40% of attending psychiatrists felt confident in speaking to patients about proper storage of firearms, and only 35% felt confident recommending safety training.34
Training is required to achieve proficiency in making clinical violence risk assessments, an unmet need in academic medical institutions. In a survey of pediatric, emergency medicine, and surgery residents caring for children and adolescents who presented with violence-related injuries, just 47% felt competent discussing violence risks and safety, with the majority of respondents citing lack of training (75%) and insufficient time (89%) as barriers.35 In a separate survey, only 30% of fourth-year medical students were “satisfied” with their curricular education on suicide risk assessments.36
Instruction and experience have been shown to improve the quality and frequency of risk assessments. In a retrospective case control study that sought to measure the accuracy of physicians’ violence risk assessments using a 4-point assault precaution checklist, Teo and colleagues reported that violence risk assessments by attending psychiatrists were moderately accurate compared with a presumed gold standard of assessments by experienced clinicians with doctorate-level degrees in mental health.37 In contrast, assessments by residents were “no better than chance.”37 While experience is important (as suggested by these findings), the authors concluded that having less training is also associated with inaccurate violence risk assessment.37 Similarly, Wong and colleagues asked 59 psychiatric residents and 11 staff psychiatrists to identify relevant risk factors for violence in a hypothetical patient with homicidal ideation, using the Historical Clinical Risk Management-20 structured judgment tool.38 The authors reported that attending psychiatrists performed significantly more robust risk assessments (14.7 risk factors assessed) than less experienced residents (8.5 risk factors assessed).38 They also found that more risk factors were elicited by residents who were in a higher year of training or those with more robust education on risk assessment and concluded that experience and relevant education were associated with more accurate risk assessments.38
In addition to increasing the accuracy of risk assessments, training has also been shown to improve confidence among clinicians and increase the frequency of firearm safety–related screenings. Pediatric residents who received online firearm injury training were significantly more confident about their ability to make appropriate referrals when dealing with firearm injury prevention than those who did not receive such training,39 and psychiatrists with formal education in firearm safety–related risk assessment were 13 times more likely to counsel patients about firearms and screen for gun violence threats than those who did not receive training on firearm safety.40
While more research is necessary, some evidence suggests that physician-directed firearm violence prevention counseling may improve outcomes by fostering risk-reducing behaviors, such as safer firearm storage. In one trial, 137 pediatric practices were randomly assigned to either an office-based violence prevention intervention or a control group in which an educational handout was provided.41 In the intervention arm, there was a 10% increase in firearms stored safely with cable locks during the study period compared with a 12% decrease in safe storage in the control group.41 In a nonrandomized study, 106 families with adolescents suffering from major depressive disorders received information about suicide risk and were urged to remove firearms from their homes. At the end of the 2-year follow-up period, 27% of those who had guns at intake reported removing them from the home.42 More research is needed to understand and develop optimal firearm violence prevention counseling strategies for clinical practice.
Crafting a Path Forward
Given the extent of gun violence in the United States and the widespread consideration of ERPO laws, the medical profession needs to ensure that its clinicians are prepared to engage in conversations about firearm access and gun violence prevention. Academic medical centers can consider several mechanisms for incorporating integrated gun violence risk assessment and education into medical education.
Some medical schools have begun to develop and study educational initiatives to meet these critical training needs. One randomized trial of 56 medical students and residents evaluated the impact of a 3-hour workshop that included an overview of firearm violence, violence risk factors, and individualized feedback on violence screening skills. Compared with the control group who received no specific training, the intervention group demonstrated increased performance with standardized patients on screening, identification, and management of violence-related scenarios.43 In 2016, the Washington University School of Medicine in St. Louis offered a course entitled “Gun Violence as a Public Health Issue,” taught by experts from Washington University in St. Louis, Saint Louis University, and local community organizations. In addition to teaching about firearm access and legislation, the course also focused on firearm injury risks, violence intervention programs, and training medical students in strategies to reduce gun violence. Students in the course were asked to design proposals for how gun violence prevention can be integrated into the standard medical school curricula.44 Recognizing the important roles of social workers, case managers, nurses, and other team members in risk assessment, much of this education could also be delivered in the context of interprofessional training programs. Including perspectives and uplifting voices of survivors of violence and other affected community members is critical to the development of these efforts.
Our medical school (Harvard Medical School) has also incorporated firearm-related suicide and homicide risk assessment training into its curriculum in several areas, including the first-year longitudinal clinical course, the psychiatry preclinical course, and the psychiatry clerkship. Additionally, in a new postclerkship case-based session, physicians and ethicists guide students in discussions about the implications of addressing a patient’s access to cars (e.g., in the cases of dementia or vision loss) compared with firearms (e.g., in the case of suicidal or homicidal ideation). Integrating new courses into the curriculum is challenging with the limited time available in medical training programs; thus, intentional efforts to weave any such curriculum into existing coursework will be important.
Graduate medical education programs should also consider expanding firearm-related risk assessment training across more specialties. While many psychiatry residencies devote resources to developing skills in risk assessment, primary care physicians, pediatricians, surgeons, obstetrician–gynecologists, and emergency medicine physicians may need to perform similar risk assessments for violence and impulsivity, yet they receive little or no specific training on these. The Massachusetts Medical Society’s firearm violence online course presents one example of how to include clinically relevant gun violence prevention training in continuing medical education.45 This course and others like it ensure that physicians have access to updated information pertaining to firearm-related violence (e.g., on ERPOs) in a rapidly evolving legislative climate. Importantly, in states without ERPOs or similar types of legislation, physicians can still play an important role in counseling and discussing risks. Any gun violence–related educational initiative should incorporate an overview of the relevant laws in that particular state.
As states expand efforts to prevent gun violence with evidence-based policies that require firearm violence risk assessments, the medical community should prepare to take on this charge. Academic medical institutions can begin by examining educational curricula. Using models from psychiatry residency programs, medical societies, and medical schools that have been early adopters of these educational initiatives, academic institutions can develop innovative methods to achieve better competency in gun violence risk assessments. With more than 100 Americans dying every day because of firearm-related violence,3 the medical community cannot allow a lack of education or commitment to stand in the way of joining the national effort to prevent gun violence and save lives.
The authors wish to thank Edward Hundert, MD, dean of medical education at Harvard Medical School, for providing information about risk assessment–related curricula.
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