Education: My best weapon in injury prevention

By Eric Fleegler, MD, MPH, attending in Pediatric Emergency Medicine; co-author, “Attempts to Silence Firearm Injury Prevention.”

I remember the first time I fired a shotgun: the noise was extreme, the kickback stronger than I anticipated. It was exhilarating. I was 17 years old.

At the time I was struck by the raw power of the gun, the enjoyment of the moment. Twenty-two years later I am struck by the potential on that day for a devastating accident. I was in the backwoods of a classmate’s house. We were by ourselves, shooting an old microwave in the middle of the day.

As a pediatric emergency medicine doctor I see the results of bad decisions every single shift: bike accidents that occur without helmets which lead to permanent brain injury. Intoxicated teenagers who aspirate their own vomit and end up in the intensive care unit. Sexually active adolescents who don’t use protection and get infections—or get pregnant. A 10-year-old child accidentally shot in the thigh by his friend while playing with his dad’s gun.

Discussions about risky behaviors are too late for these kids. They needed guidance, at regular intervals, prior to these incidents—the kind of guidance that is the mainstay of what we do as health care providers. Asking patients about tobacco, drug and alcohol use, sexual activity, and finding out if they are depressed, have suicidal thoughts and have access to weapons that can readily kill them is vital to my work as an emergency medicine physician. 

Eric Fleegler, MD, MPH

In January of 2011 I was stunned to read about a bill submitted to the Florida legislature that would prohibit health care providers from talking to patients about firearm ownership. The original bill designated an inquiry about firearm ownership by a physician as a “felony of the third degree,” punishable by a fine of up to $5 million and up to five years in jail.  Over the next five months the penalties of the bill were moderated and on June 2, 2011, the bill was signed into law by Governor Rick Scott. Though a preliminary injunction has been ordered against this law, five other states (Alabama, Minnesota, North Carolina, Oklahoma and West Virginia) have since  introduced bills barring physicians from asking about guns in the home.

The bill was written in response to an unfortunate incident in Ocala, Florida in July, 2010.  A pediatrician asked a parent, “Do you keep a gun in the house?” The mother refused to answer, and at the end of the examination the doctor told her she had 30 days to find a new pediatrician. The mother was extremely upset; the pediatrician stated he provides safety advice to families with firearms, just as he gives advice to families with pools to prevent drowning, and to young drivers when he asks about cell phone use while driving.

I feel this doctor made a mistake. Our patients are not going to always do as we wish. Some of our patients will make decisions that fundamentally disagree with, and we as physicians have to decide how we want to further the discussion—and provide the best care we can—without alienating them.

My colleagues and I wrote an article in response to this new law titled, “Attempts to Silence Firearm Injury Prevention,” published today in the American Journal of Preventive Medicine. In the article we analyze the research related to firearm injury prevention, including:

Often, when I describe the content of our article, people ask, “Why would a doctor ask about gun ownership?” Sometimes people are polite; sometimes they are hostile. So much of the work of injury prevention is invisible to our patients. They often do not realize the check boxes checked in doctors’ heads as we run through our lists of questions that may lead to further questions and discussion. “Do you use a car seat? How often?” I ask. “Every time,” the mom replies. ‘Check’ I say in my head, no further discussion needed.

[Read coverage of Fleegler’s article in the The Boston Herald, Washington Post and Boston Globe.]

It’s much the same when we ask if families have a gun. If they say yes, we aren’t going to try to take it away or report them. We are going to ask where and how they store it. We are going to talk about ways to keep people safe around firearms.

Distribution of firearm deaths by fatality rates and number of people killed by firearms. Data are for 1999 to 2007. Click to enlarge.

As a doctor, I share a responsibility with the parents and my patients for their health and safety. To be able to provide the best advice that helps keep patients healthy and safe, I need to know the risks they face. I need to ask questions about all sorts of things. Because firearm injury is a real risk to their health and safety, I need to ask about guns.

The medical community does not deny anyone their constitutional right to own a gun. In fact, like every other profession, there are many doctors who are responsible firearm owners. What we are trying to do is share information and strategies that keep patients safe.

Silence does not promote thought. If a brief conversation can save a child’s life from an accidental gunshot, I for one think it’s a talk worth having.