'On the frontlines of public health': Physicians leverage trust against firearm violence

Key takeaways:

• Firearm injury is a leading cause of death among children and adolescents in the U.S.
• Physicians can play a role in prevention by counseling patients on safe storage, offering cable locks and more.

Through counseling and advocacy, primary care providers can play an important role in preventing firearm injury, according to experts.

Primary care providers often “find themselves on the frontlines of public health and safety issues,” and this offers them “a unique opportunity to discuss those topics in the exam room and in their communities,” according to Jennifer L. Brull, MD, FAAFP, president of the American Academy of Family Physicians (AAFP).

“Many of us have seen first-hand the devastating impact of firearm violence and misuse,” she told Healio. “We have a responsibility to advocate for safety in our communities and to talk with our patients about it.”

In a recent research letter published in JAMA Pediatrics, Eugenio Weigend Vargas, PhD, a postdoctoral research fellow at the University of Michigan, and colleagues reported that from 2018 to 2022, national child and adolescent mortality rose 18.8% — more than double the from 2013 to 2017. The increase, they wrote, was driven by a 22.8% jump in deaths related to injury, mostly caused by overdoses and firearms.

“That indicated to us that this is a growing problem,” Vargas told Healio. “Firearms became the number one cause of death somewhere between 2018 and 2022, and this is also the number one cause of death in half of states.”

When broken down by state, just six saw decreases in mortality among those aged 1 to 19 years. For the other 44 states, the rise was “primarily driven by injury-related deaths — specifically, firearm deaths,” Vargas said. Firearm injury served as the main cause of death in this age group across 25 states, and ranked in the top two causes in 42 states.

“More attention needs to be given to how mortality is increasing among youth and children,” Vargas said. “There are policies that could be implemented federally, and at a state level as well.”

But even without major policy changes, there are ways PCPs can start working toward solutions, according to Brull and Vargas.

Solutions

In a study published in JAMA Pediatrics, Rinad S. Beidas, PhD, Ralph Seal Paffenbarger Professor and chair of the department of medical social sciences at Northwestern University, and colleagues evaluated a program that helps PCPs get involved with firearm injury prevention.

The randomized study compared two methods to implement a secure firearm storage program into childhood check-ups. Half of the 30 clinics received a change to the EHR documentation template that PCPs used for these visits, adding a prompt to discuss secure firearm storage and offer a free cable lock. The other half received that change as well as facilitation — “targeted problem solving or consultation around how to embed programs into that pediatric primary care setting” — which was more effective, the researchers wrote.

In usual care, cable locks and discussions about firearm storage are very rarely offered, Beidas said.

“Our estimates from surveys suggest that no more than 2% of clinicians are having these conversations and offering free locks to parents within the context of usual care, even though it is recommended and supported by the American Academy of Pediatrics,” she said.

But with their implementation approach, “we were able to see a very large increase in delivery of the program,” Beidas explained.

“My personal perspective is that we need to take a multilevel, evidence-based public health approach to reducing firearm injury and mortality, and this study is an example of a large-scale approach that we can take now, nationally, to reduce suicide, which happens to be a large portion of injury, mortality and unintentional injury,” Beidas added. “Given that our problem is continuing and we have a way to implement an evidence-based approach, I think we ought to be doing it.”

Beidas said this program is scalable because it is common ground in a divisive world.

“It is not political; it is evidence based,” she said. “Everybody agrees that we want to keep young people safe, and everybody agrees that we want to ensure that firearms are not accessed in an unauthorized manner.”

Of course, within the broader context of the political climate in the United States, the conversation can be sensitive, Beidas said. But the goal is just to “meet people where they are at” and work with them to move toward secure storage.

“Rather than taking the stance of ‘the only safe home is the home where the firearm is stored unloaded and locked and the ammunition is locked separately,’ we think ‘how can we work with families to join in the shared mission of keeping young people safe and move them towards more secure storage?’” she said.

Beidas added that from her perspective, these are conversations that PCPs can have “as part of the anticipatory guidance that they already do around safety for young people.”

“Pediatric clinicians are trusted messengers about safety for young people,” Beidas said. “That's their job. Pediatric clinicians talk about bicycle helmets. They talk about seat belts. They talk about all kinds of things that we can put into place to keep young people safe. This is part of that now.”

Brull, who practiced for more than 20 years as a family physician in rural Plainville, Kansas, said that PCPs play an important part in injury prevention counseling, which includes best practices for safe firearm storage.

“When you live in a rural community, addressing firearms safety with your patients is a routine part of the conversation,” she said. “Counseling on gun safety is especially important for raising awareness for at-risk patients, particularly for pediatric and adolescent patients and individuals who experience suicidal ideation.”

Counseling and advocacy

Brull said that, as part of routine preventive care, PCPs encourage counseling and interventions, which includes asking patients about their access to firearms.

“For toddlers and small children, I asked a routine screening question with context appropriate to the family,” she said. “For example, in my patients who were farmers, I often asked ‘Do you all hunt? Have guns?’ and if the answer was yes, I followed up with ‘How do you store your guns?’ and counseled about safe storage.”

With adolescents and older children, Brull said she started the conversations with a similar question but followed up by asking if they have taken hunter safety — “a firearm safety class offered throughout the area and fairly standard for every young person who hunts.”

“Just like nudging your patients to take swimming lessons in the summer, reminding them to take opportunities to talk about and learn firearm safety is part of every pediatric conversation,” Brull said.

PCPs also screen patients at high risk for firearm-related injuries, including those with alcohol or drug use disorders, depression, intimate partner violence and anxiety with suicidality, Brull noted. And if anyone has a positive screen, PCPs “are well equipped to discuss strategies for limiting or removing gun access as part of a management plan.”

“Physicians of all specialties can help prevent gun violence within their communities by engaging in proper screening and treatment of depression, referring patients to appropriate services, and talking with patients about the safe storage and handling of guns,” Brull said.”PCPs develop trusting relationships with patients and families over time, which allows them to approach these conversations incrementally and perhaps with more engagement from the patient.”

Ultimately, she said PCPs “have a responsibility to advocate for safety in our communities and to talk with our patients about it,” but their role does not have to stop when they take off the white jacket.

“Outside of the exam room, family physicians can also help prevent suicide and intentional injuries and deaths by advocating for policies that prevent violence at the community, state and federal levels,” Brull said. “Common sense safety provisions that address gun violence and promote safe and responsible gun ownership are a first step.”

For example, Brull noted that the AAFP supported the Bipartisan Safer Communities Act, which included school safety measures, protections to invest in mental health programs and protections to restrict access to firearms.

“Stronger gun trafficking and laws regarding straw purchases, when someone buys a firearm for someone who cannot legally do so, could help reduce gun violence by discouraging those who are legally able to buy guns from diverting weapons to criminals and those living in jurisdictions with restrictive firearm ownership requirements,” she said. “Reinstating a ban on selling assault weapons and high-capacity magazines could also reduce gun violence.”

The AAFP also endorsed the bipartisan Kid PROOF Act, which would allow clinicians to distribute lethal means safety supplies, like safes and lockboxes, to parents so they can better protect their children from overdose or suicide.

“Evidence has shown that lethal means safety is one of the most effective ways to prevent suicides and save lives,” Brull said. “Given the impactful, trusting relationships that family physicians cultivate with our patients and their families, I believe our promotion of these types of interventions can play a key role in reducing firearm-related injury and morbidity for children and adolescents.”

Finally, it is critical that Congress fund more comprehensive research to examine the root causes of firearm violence, Brull said.

“I can’t emphasize enough the importance of funding for gun violence research that can identify the key causes of the gun violence epidemic, as well as highlight opportunities for reducing gun violence,” she said. “A comprehensive data collection surveillance system could provide valuable information for public health researchers to study gun violence and the most effective ways to address it.”

References:

• Beidas RS, et al. JAMA Pediatr. 2024;doi:10.1001/jamapediatrics.2024.3274.
• Vargas EW, et al. JAMA Pediatr. 2024;doi:10.1001/jamapediatrics.2024.2894.