The average American child is 13 times more likely to be murdered with a gun than are children in other industrialized countries, according to the Harvard School of Public Health. And that’s after the gun homicide rate in the United States went down 49 percent since its 1993 peak, paralleling a general decline in violent crime, as illustrated by a Pew Research Center analysis of government data.
More than 900 children in the U.S. die in homicides each year, the majority of whom (51 percent) are shot by a relative, according to an NBC News analysis of 25 years of homicide reports. The most recent analysis of U.S. homicide rates from the Centers for Disease Control and Prevention shows that firearms were the cause of 11,078 deaths out of 16,259 homicides recorded in 2010.
The American Medical Association, the American College of Physicians and U.S. Surgeon General nominee Vivek Murthy are calling gun violence a public health crisis. Physicians, including family doctors and general practitioners, are increasingly seen as a crucial link in the prevention chain.
While gun-control advocates are lobbying for measures such as bans on assault weapons, limiting ammunition magazines, and strengthening background checks, debates tend to focus on lapses in our mental health system and the need for increased detection and prevention. Preventing gun fatalities, many say, ultimately turns on keeping guns out of the wrong hands.
All U.S. states allow citizens to carry certain concealed weapons in public for lawful purposes with the exception of felons, persons proven to abuse controlled substances, individuals with a history of domestic violence, and those deemed mentally unstable or dangerous. However, approval processes and waiting periods for gun purchases vary widely by state.
Some states require local law-enforcement agencies to sign off on concealed-weapons permits, and ask applicants to disclose mental or physical conditions that could prevent them from handling a gun safely. Law enforcement in some states may also require applicants to provide the name of a doctor who can testify to their mental or physical fitness to carry a concealed weapon, based on their health history.
North Carolina is among the states where law enforcement can ask physicians to sign off on competency permits, but a recent survey of the state’s doctors shows many of them worry they may not be equipped to judge their patients’ physical and mental ability to handle concealed guns safely. The U.S. currently lacks training programs and comprehensive standards to guide doctors in making such assessments, so physicians are reduced to using their best clinical judgment.
The survey of physicians in North Carolina found that many are concerned about the increasing number of requests they are receiving to assess their patients’ competency to carry concealed weapons. The majority of doctors who answered the survey said they did not feel they could make an adequate assessment.
The study, published as a research letter in the June 2014 issue of The New England Journal of Medicine, is believed to be the first to examine doctors’ attitudes, beliefs, and behaviors regarding their emerging role in the assessment of competency for the licensing of concealed weapons.
The survey was sent to 600 physicians registered with the North Carolina Medical Board and who were in active practice as of October 2013. Of the 600 surveys sent, 222 completed surveys were returned. The majority of respondents were male, had been in practice for more than 15 years, and saw at least 10 patients a day. Thirty-five percent of respondents were family physicians, 38 percent were psychiatrists and 27 percent were internists. Eighty physicians (36 percent) indicated that they owned a gun.
Twenty-one percent of doctors who responded to the survey said they had been asked to sign off on concealed-weapons competency permits, and indicated they had done so 80 percent of the time when asked. But most of them admitted they did not feel comfortable assessing patients’ physical competence to carry a gun. A sizable minority also expressed concerns about mental competence evaluations. Most physicians (84 percent) felt that medical assessments for competency should be conducted by physicians specifically trained in doing so.
“There are things we can do now to change this,” Dr. Kathy Barnhouse, a professor of family medicine at the University of North Carolina School of Medicine and co-author of the study, said in a press release. “We discovered that the great majority of physicians feel that assessments for concealed weapons permits should best be done by providers specifically trained in making such assessments, presumably with standards to make assessments about mental and physical competence.”
Dr. Adam Goldstein, a study co-author and professor in the department of family medicine at UNC, thinks the problem lies with a lack of uniform standards and public policies across states to determine what is dangerous enough to justify denying a permit.
“Doctors are qualified to do this, but they need guidance,” Goldstein said in a telephone interview. “The physician that best knows the patient is the best type of physician to do these assessments. In most cases, that would be the primary care physician. Doctors who have special training, who may not be the primary care physicians, may also be qualified to do it. The type of questions being asked involve physical and mental capacities. The problem is there are no criteria for assessing them.”
When law enforcement agencies ask doctors to attest to an applicant’s mental or physical fitness to carry a concealed gun, they may send a minimal form to the doctor, and sometimes a request for more detailed medical records. The problem is, Goldstein says, the current forms are not comprehensive enough for this type of assessment. The Department of Transportation has more detailed regulations about who can conduct “transportation physicals” for commercial motor vehicle licenses.
“When you do a transportation physical, there are forms that ask about cardiac, respiratory, emotional, neurological, and psychiatric conditions," Goldstein explained. "If, for instance, one has neuropathy, dementia, or a cardiac condition, you would want to know how severe it is. We could develop such forms [for concealed weapons permits] relatively quickly and educate providers about what the expectations are.”
In the absence of a clear protocol, doctors may have different opinions on what constitutes mental and physical competence to carry a concealed gun. In a 2013 article in The New England Journal of Medicine, Goldstein and co-authors wrote:
Reasonable physicians might disagree about whether patients with severe Parkinson's disease, prior strokes, atrial fibrillation, seizures, or chronic pain are physically competent to use a weapon safely, as well as about whether people who have a history of depression, substance or alcohol abuse, anxiety, or insomnia or who are taking psychotropic medications are mentally competent to do so. Guidance is needed regarding the need and protocols for collection of urine toxicology or blood alcohol reports to rule out drug or alcohol use before signing off on permits.
The North Carolina survey also showed that doctors are concerned about the potential ethical consequences participation in this assessment might have for the doctor-patient relationship. While the Affordable Care Act forbids the collection and recording of data about patients’ gun ownership, the Obama administration has made it clear that health laws do not prevent physicians from disclosing necessary information about a patient to law enforcement, family members or other people when the patient is deemed to present a serious danger to himself or others. But the American Psychiatric Association has cautioned against laws requiring doctors to talk to law enforcement about patients who may appear to pose a threat to themselves or others.
“Because privacy in mental health treatment is essential to encourage persons in need of treatment to seek care, laws mandating psychiatrists and other mental health professionals to report to law enforcement officials everyone who appears to be a danger to themselves or others are likely to be counterproductive and should not be adopted,” the APA recommended in a 2013 statement, while advocating for "an integrated system of mental health care for the 21st century."
The North Carolina survey showed that psychiatrists did not feel any more comfortable assessing patients’ capability to carry a concealed gun than their general-practitioner peers.
Although law enforcement has the last word in granting or denying a gun permit after taking into consideration a slew of factors, doctors are no doubt the most qualified to assess patients’ physical, mental, and emotional challenges. A 2013 Annals of Internal Medicine article argued that doctors can play various roles in the gun policy dialogue: from researchers and policy advocates to managers of patients’ fear of victimization.
But doctors involved in the concealed-weapons permitting process must balance their responsibility to the public, their relationships with their patients, and their personal beliefs. At least 20 percent of the physicians surveyed in North Carolina said they refused to fill in gun-permit competency forms when asked to do so, worrying their input could damage the doctor-patient relationship and patients’ trust in healthcare providers.
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