Update: The JGIM has just published an article on this that looks promising, but I haven’t had time to read it yet. The abstract claims ” existing data on physician-initiated conversations with patients about guns support a positive prevention effect.” Below I link to AAP guidelines that reference two negative RCTs on this subject. Obviously, need to go to the data. Don’t think it changes the thrust of that part of my argument, which is that there are probably good and bad ways to talk about guns and we should look at that question carefully.
The full 11th Circuit Court of Appeals is preparing to re-hear Wollschlaeger v. Governor of Florida next month, the legal challenge to Florida’s Firearm Owners Protection Act that prevents doctors from talking to patients about guns. A panel of three judges has upheld the law three separate times under differing levels of First Amendment scrutiny. First things first: this is a bad law, and the decision to uphold it is bad – Dahlia Lithwick and Eugene Volokh talk more about the implications for speech more generally. And the Harvard Law Review has an interesting commentary on moral conscience in professional practice – more on this later.
But even if the law’s upheld, I think lot of the writing about it from medical corners has been unhelpful.
I: Yes, you can still talk to your patients about guns.
Last week, the NEJM worried that “If FOPA is upheld, other states may enact laws regulating physicians’ speech pertaining to firearms. If so, physicians’ ability to counsel patients about gun safety will be significantly compromised.” Writing in the New York Times in 2014, Aaron Carroll laid out the case for anticipatory guidance about safe gun ownership in pediatric practice, and voiced similar concerns.
A recent piece in Annals of Internal Medicine, on the other hand, suggests that the law does not prevent doctors from asking about guns in situations where there is particular relevance to patient care. They offer this table as a guide.
So, can pediatricians talk to parents about guns and gun safety or what? It’s worth going to the law itself and the Court’s decision to uphold it. Here’s the law, in part:
The plaintiffs challenge that the “relevance” clause I’ve highlighted is too vague to be enforceable. The Court spends a fair amount of time clarifying this (starting on page 28). The gist is that by the plain meaning of the words, the law only implies that doctors should not ask about guns when they know or have good cause to believe that the question is not relevant. So Annals gets it mostly right.
Here’s the Court again:This, I think, is what Annals misses. Nobody wants to be subjected to an investigation by the Board or face a potential malpractice suit. And although I think the court is pretty clear that if you are practicing according to the accepted standards you are likely to be protected, the law still introduces uncertainty to physician practice, and empowers patients to respond to seemingly reasonable questions with costly legal or professional complaints. So even with the assurance of protection, doctors are going to be less likely to talk to patients about guns. What do we do about that?
II. How did we get here?
In the case that sparked the legislation, a woman brought her 4-month old to a pediatrician in Ocala, Florida. He asked her if she kept guns in the home. She asked him why he was asking. He may have explained that it was a routine question about preventative health and safety, or he may have said nothing, depending on whose account of the interaction you believe. At the end of the visit, he told her to find a new pediatrician. She went to the news. A number of other people had similar stories, including Florida state legislators.
Accidental injury, homicide and suicide are major causes of death, especially in otherwise healthy young people. Statistically, children in homes with guns are at greater risk of harm. Although there are ways to mitigate those harms – lockboxes, trigger locks, storing ammunition separately from the gun – many people don’t use them. The American Academy of Pediatrics “Bright Futures” guidelines recommend counseling parents about these safety techniques, and that the safest homes are ones without guns.
It’s a little bit curious that those same guidelines note two RCTs that have looked at whether counseling patients about gun safety leads to safer gun practices. The answer is no.
One of the arguments made by the court is that it is “common sense that a doctor has no right to express to a patient her religious, political, or moral beliefs, – all irrelevant to medical care”. The Harvard Law Review commentary I mentioned above defends the right of doctors – under existing law and precedent – to cultivate their own practice style and to set for themselves the boundaries of personal and professional identity. “As all people do throughout their careers,” they write, “a doctor must decide how important it is for her to communicate her personal beliefs to clients, what she is willing to risk in order to do so, and whether she is willing to pay the market price for her choice.”
It’s a nice theory, but how does it work in practice?
Let’s go back to Ocala. The pediatrician in question, Dr. Okonkwo, was medical director of his practice. Here’s how he explained his decision to terminate the mother who refused to answer his questions about guns:
So, this is bullshit.
Building trust is an essential skill for a doctor. It is something to be earned, not due to us because we wear a white coat and have a diploma on our wall. But there’s more: the kinds of patients who don’t instinctively trust their doctors, and refuse to divulge personal information simply because they were asked to, are also the kinds of patients who are marginalized, vulnerable, and have reasons to be distrusting. They are the kinds of patient whose insurance is less likely to reimburse well.
I’d argue this doctor is staking his practice on objectionable moral grounds, even if he is within his legal rights. But what’s the “market price” for that? We don’t know how to tell a good doctor from a bad one in real time, and even if we did, it would be hard to get that information to patients in a way that was both reliable and fair. As it stands, doctors are free to develop a practice “style” based on their moral principles and scientific beliefs, etc, but let’s say you want a doctor who believes she should have to earn your trust, and has some facility at doing with patients with varying interests and values. Where will you find that information? Unless you know someone who knows someone, you’ll learn it from trial and error, at the cost of time and money. Worse, you’ll get trapped with a doctor you don’t like. If you’re also poor and sick, you have little recourse.
So is it any wonder we get bad laws and angry patients? Or other cumbersome attempts at standardization of practice?
III. Doing the same thing over and over and expecting it to be different.
If counseling patients about gun safety doesn’t make them safer gun owners, why do we keep doing it? Why do we insist on the right to keep doing it?
It’s not just guns that are the problem here. Educating vaccine-hesitant parents about the clinical data on vaccine safety and efficacy can backfire. Even on issues that aren’t politically polarized, it turns out that sometimes it takes more than an explanation to get people to change their mind or behavior. But the dogma here seems to be that if we proclaim the truth louder it will be more convincing. A better approach might be to separate the practice of medicine a little from the notion that we are simply promoting scientific truth. In reality, we’re selling health. And to do that we need to know what sells.
This gets back to a point I’ve promised will be fundamental for this blog. It’s not particularly useful to think of doctors as counselors of scientific truth, which patients then accept or reject. All of our choices are between competing claims of authority and the grounds for accepting those claims. So from a physician’s standpoint, getting a patient to understand what the data says about vaccine or gun safety is only part of the job. The harder part is to give them reason to believe that we are trustworthy and reliable, reporting all the data, carrying no ulterior motives, capable of understanding and respecting people with very different values and priorities (on guns in particular, this piece by Dan Kahan and Donald Braman is very much worth reading).
Data alone won’t do it, and neither will firing a patient who doesn’t start off sharing those beliefs.