Articles, Blog

Preventing Firearm-Related Injury and Death: A Targeted Intervention

[MUSIC PLAYING] Welcome to preventing
firearm-related injury and death, a targeted
intervention. My name’s Garen Wintemute. I’m an ER doc and
I became involved in firearm-violence
prevention because I believe there is a moral
imperative to prevent firearm-related harm
that’s every bit as compelling as the moral
imperative to treat it. There is a practical reason too. Most people who die
from firearm injuries never make it to the hospital. They die where they’re shot. To prevent deaths
from firearms, we need to prevent people
from getting shot in the first place. I’m Emmy Betz, and I’m
joining the conversation from the University of
Colorado, School of Medicine. I’m also an ER doc, and
probably like most of you, I’ve lost family members
and friends to suicide. I also care for patients who
have been hurt by firearms or are at risk of future
firearm injury or death. I work on this issue to
help patients I care for and to help the many who
might not make it to my ER. I’m Megan Ranney, an
emergency physician from Alpert medical school
at Brown University. I’m involved in this
work because all of us as physicians have
stories of patients, hurt or killed by
gunshot wounds, who we wished we could have saved. But most of us also have
personal stories about the way that gun violence
has affected us. It’s time to do better
for our patients and for our communities. I’m Rocco Pallin, and I’m
the director of the What You Can Do Initiative. As researchers, my
colleagues and I study the causes
and consequences of firearm violence. But we want to do more. Our goal is to translate that
knowledge into strategies for preventing
firearm-related harm, including helping health
care providers play a role in reducing
firearm injury and death. We’re going to take
a comprehensive look at firearm injury and death. We’ll lay groundwork
for thinking of firearm-related harm as
a public health problem. And we’ll cover the epidemiology
of firearm injury and death in the United States. It’s essential we think
about firearm-related harm as a public health problem
and that we conduct translational research on how
to move from basic knowledge to effective prevention efforts. But what can we do now while
we wait for those research results? As health care providers
and as thought-leaders in our communities, there is a
simple, targeted intervention that all of us can
start using now. It doesn’t deal with
policy or partisanship. It simply takes place within
the context of routine patient care with the patients with
whom we’re already interacting. And it’s not about
asking everyone if they have a firearm. When you feel that patients may
be at risk of firearm injury, first, talk to them about
access to firearms, second, provide counseling on safe
firearm practices, when appropriate, and third, take
action when the risk is acute and someone is in
imminent danger. This is the bulk of what
we’re here to talk about– the who, what, where
and how of clinical counseling for reducing the risk
of firearm injury and death. And you don’t have
to own a gun or even have used one to discuss firearm
safety with your patients. You just need to
learn about it, just as you’ve learned to talk about
insulin or similar medications with your patients,
even if you’ve never used them yourself. Let’s start with a little
background on this project. This presentation
is part of What You Can Do Initiative,
which we developed following the mass shooting in Las Vegas,
Nevada in October of 2017. For many years, I’d
heard from providers who wanted to get involved
in firearm-injury prevention, but who didn’t know
where to start. After Las Vegas,
interest grew rapidly. I wrote a commentary in Annals
of Internal Medicine asking readers to make public
commitments to provide counseling on firearms. We solicited feedback on how
often providers ask and what reasons they have for not
asking, when they don’t. We learned that providers
needed help in two ways. They needed more information
on how to identify risk factors and how to ask the
firearm questions and they needed materials
on firearm safety to give to their patients. The material that
we’ll cover is derived from the best
research in the field and from expert opinion
where research is lacking. The science that would
support or define a most effective clinical
strategy for preventing firearm injury and
death is incomplete, but our patients can’t
afford for us to wait. [MUSIC PLAYING] Dr. David Satcher, Director
of the Centers for Disease Control, said of
violence in 1993, “if it’s not a health problem,
then why are all those people dying from it?” In the 21st century,
at least so far, we’ve made little progress
in reducing firearm deaths. Let’s take a look at all those
people he was referring to. Who are they? How are they dying? And what can we make of the
geographic and demographic trends in firearm deaths? It shouldn’t surprise us
that deaths from firearms vary geographically. Firearm injury and death
affect the entire country, but in different ways. This we should expect. Firearm ownership and use
also vary across the country and significantly between
rural and urban areas. Here’s another look
at geographic patterns of firearm deaths. One important finding
is that homicide is highest in the south,
while suicide rates are highest in the
inter-mountain states, like Montana and Wyoming. When we dive deeper
into the data, we learn how people are dying
from firearms in the US. The results can be surprising. For example, only about
1% to 2% of firearm deaths occur in public mass shootings. With other types of
firearm-related harm, many of us can pretend
that we’re not affected. But mass shootings
don’t allow us to ignore that we too could be victims. That said, we believe that
the attention of policymakers and the attention of
health care providers should be on the
prevention of all forms of firearm-related harms,
not just mass shootings. So let’s take that broader look. In the United States
in recent years, there have been
nearly 40,000 deaths from firearms and more than
115,000 nonfatal injuries annually. Nearly 2/3 of
deaths are suicides. Most of the other
third were homicides. The annual cost to
firearm injury and death was estimated as
being $229 billion in 2012 alone,
including $8.6 billion in direct costs, things
like health care. The broad spectrum of all
types of firearm-related harms is where we as providers have
an ability to help our patients. Research largely stalled
more than 20 years ago, and perhaps as a result,
comprehensive intervention has been lacking. But it does not
have to be that way. Let’s take a look at another
and analogous public health problem. These days, similar numbers of
people die from firearm injury as for motor vehicles each year. But the long term downward
trend in motor vehicle deaths, especially considering
increasing numbers of drivers and miles driven,
is proof of what public health interventions can do. With motor vehicle
injuries, we faced a crisis, recognized an
epidemic, and decided to do something about it. Research was
prioritized and funding was allocated to
characterize the problem and best understand
how we could intervene. Regulatory agencies
and Congress were ready to act on the
researcher’s findings and their recommendations. After a short time, the
intervention halted the rise in death, with ups and
downs, including factors like the economy, changes
in road and car design, policies about alcohol, deaths
from crashes continued to fall. We saw a greater than
60% per capita decrease and a greater than 80%
decrease, accounting for the overall increase
in miles traveled. In 1999, CDC called this a
20th-century public health achievement. With firearms, we’ve
done the opposite. The federal government instead
of promoting and funding research, has largely
abdicated its responsibility. The result, rates of firearm
mortality haven’t declined. In fact, we’ve just seen
these trend lines cross for the first time in history. To best understand the risk
of firearm injury and death and potential interventions
to prevent it, let’s first look at who’s
dying from firearms and why. There’s a general misconception
that firearm homicides outnumber firearm
suicides, and perhaps that leads many
clinicians to think there’s not much they can
do to make a difference. However, suicide accounted
for nearly 60% of deaths from firearms in
the United States, in the most recent
annual data available. Even when firearm-homicide
rates were at their highest in the
late 1980s and early 1990s, firearm-suicide
rates were higher. The steady increase in
firearm suicide and decrease in firearm homicide over
most of the last two decades meant that there was
effectively no net change in firearm deaths. More recently, as we’ve said,
both suicide and homicide have been increasing. Overall, males are at much
higher risk for firearm death, both homicide and suicide. This graph is one you’re
familiar with, even if you’ve never seen it before. It shows the most
up-to-date death rates from firearm
homicide among males, by age and race or ethnicity. Note that young black
males firearm-death rate is more than five times as high
as that of young Hispanic males and more than eight times
that of young white males. I’m not aware of another
major medical or public health problem for which risk
is so concentrated among a specific
age and race group, as firearm homicide is
for young black men. It’s important to emphasize
that females are also at risk. While black females in
the 18 to 24 age group had a rate less than
10% that for black males in that age group,
the homicide rate for black females from
birth through age 39 exceeded that for white
males of the same age. This chart you might
be less familiar with. It shows the recent annual
rates of suicide among men by age and race. White non-Hispanic men
are at highest risk. And not only does the
rate increase with age, it increases more
rapidly with age. We know that in recent
years, between 85% to 90% of firearm-related deaths
among black men were homicide. Between 85% and 90% of those
among white men are suicide. Let’s also quickly
take a look at rates of firearm-related mortality
among children and adolescents. Although the unintentional
firearm-death rate remains pretty stable
for youth through age 21, rates for firearm
homicide and suicide both begin steady
increases around age 12. We may have a unique opportunity
to intervene and prevent future firearm injury and
death in that period in which the rates remain low while
children are relatively young. This is the traditional public
health approach to the problem. We’ve been talking
about risk, which we all know is critical for
prevention efforts. High-risk groups
deserve our attention. There is a complementary
approach, however, called the population health approach. The population health approach
is based on the observation that most adverse health
events, the burden of illness, can occur among
people at low-risk, if the low-risk
population is big enough. Heart attacks are
a good analogy. Many people who
have a heart attack have just a few risk factors. A comprehensive
prevention approach should be both risk-based
and population-based. When we look at total number
of deaths from firearm injury, we see that after the mid
30’s, the burden shifts from black men to white men. It’s important to keep this
broader picture in mind as we prepare to discuss
firearms with our patients. [MUSIC PLAYING] What can we do as providers? First, we can identify risk. Second, we can
counsel patients who are at risk, just as
we counsel patients on healthy behaviors
and risk reduction for other health problems. And finally, we can act when
someone is in imminent danger. Let us be clear, we’re not
recommending that docs talk to every patient about this. Discussions about firearm
access are not always relevant. Rather, we should
have the discussions when, in our
professional judgment, it’s most relevant to the
health of the patient or others. To know when it’s
directly relevant, we need to be comfortable
in identifying risk factors among our patients. As we’ll see, the
reason a patient is at risk for
firearm-related harms might well be what has
brought them in for care. At-risk patients may belong
to a demographic group that’s at higher risk,
may have histories or individual characteristics
associated with an increased risk of violence, or may have
active suicidal or homicidal ideation or intent. Keep in mind, that the
patients we’re seeing might not be themselves at
risk for committing harm with a firearm, but instead
maybe the partner, family or household
member, or caretaker of the at-risk person. The patient might not be
the firearm owner either, but it’s still critical to
have the conversation when someone in the home is at risk. Let’s look at the three
risk groups in detail. Some patients fall
into demographic groups that are at higher risk
for firearm-related harm. These include children
and adolescents, for unintentional-firearm
injury, adolescent and young adult
men, for homicide, middle-aged and older men, for suicide. There are also patients who will
have individual risk factors for firearm injury and death. These patients may
have a personal history of violent behavior or
of violent victimization, abusive partners, problems with
misuse of drugs or alcohol, serious or poorly
controlled mental illness– although it’s
important to mention, that patients with
mental illness are unlikely to hurt others. They’re more likely
to hurt themselves– or impaired cognition
or judgment. There’s specific evidence on
these individual risk factors. For example, having
a firearm in the home increases risk of death for
victims of intimate partner violence by five times, even
if the victim owns the fire. Among legally authorized
firearm owners, a prior history of
violence increases the risk of future
violence by 5 to 15 times. A prior history of alcohol
abuse increases risk by about four times. Substance misuse, whether
of alcohol drugs or both, increases risk of unintentional
firearm injury, suicide, and homicide. Cognitive impairment
also increases risk for all these
types of violence. So far as is known,
the prevalence of firearm ownership
among people with these individual risk
factors is about the same as it is in the
general population. Finally, let’s consider
patients at acute risk for violence, patients with
suicidal or homicidal ideation or intent. When a patient expresses
suicidal or homicidal thoughts, it might be an
emergency and it can be critical to take
immediate action. Here’s one important takeaway. Method or means by which
a patient attempts suicide has a big influence on
whether they survive. About 90% of firearm
suicide attempts are fatal. Suicide attempts by
other means are only fatal about 10% of the time. Most importantly, research shows
that 9 out of 10 people who survive a first suicide
attempt will not go on to die by suicide. So if we can keep them from
dying in their first attempt, they’re likely to live a
normal and healthy life. Here’s another
important takeaway. Our message as
health care providers should be to reduce firearm
access for those who are at risk of injury or death. And other messages
might be relevant too. For example, some
patients may want advice from providers on whether
or not to get a firearm. And providers might want
to counsel some patients to not have firearms in the home
at all, as the American Academy of Pediatrics recommends. But for patients with
firearms, the conversation might be as simple as
counseling on the importance of safe storage practices and
on reducing access temporarily when someone is going
through a time of crisis. The first step to counseling
is to plan a tailored conversation. We should consider
what we already know about the patient and his
or her risk factors for firearm injury and death. Counseling should be
respectful and nonjudgmental, relate clearly to the patient’s
health and well-being, be conversational
and educational, acknowledge local
firearms customs, and include
appropriate follow-up. Emphasize that risk for firearm
related injury is not static. It changes as circumstances
in the home change. For example, maybe a patient
has had a firearm for years but recently had a child. You could remind the patient
that safe firearm storage is important for reducing
risk of unintentional firearm injury among children. When discussing firearms with
patients, the language we use is also important. For example, we encourage
using the word firearm, though gun is acceptable
in many cases. Awareness of local
firearm culture, respect for reason
for ownership, and a shared
decision-making approach are all important parts
of the conversations we have with our
patients about firearms. We’ll need to explain why
we’re asking about firearms. That is, why risk is increased
and why firearms, in this case, are a matter of patient
safety and well-being. We can mention the
specific risk factors we’ve identified in our
conversation with the patient. That way, the patient will see
the conversation as relevant and understand the
emphasis on safer storage. It may be appropriate to
talk about risk in general. If so, we can explain that, on
balance, a firearm in the home increases the risk of death
for everyone in the home. On average, even
after controlling for socioeconomic and other
demographic variables, when there is a
firearm in the home, risk for homicide in the home
goes up by a factor of 2.7, and risk for suicide in
the home goes up by 4.8, compared with homes
without a firearm. Of course, these
risk numbers are based on population-level
data and may not apply to your individual patient. They also may not be
appropriate to mention during an individual visit. Some providers feel
uncomfortable or uncertain starting a conversation
about firearms, so we’re going to walk through
some suggested approaches. If I’ve determined that the
patient or someone in the home is at increased risk for
injury from firearms, I know that asking about access
to firearms is important. I’ll say something like,
in situations like this, I think about safety
and need to be concerned about ways an
injury could happen, including access to
firearms and other weapons. So for example, are
there any firearms in or around your home? Or I could just assume
there is access, and instead of asking a question,
just say, so for example, tell me about the
firearms in your home. With this phrasing,
I’ve established a context that
makes the question relevant to the
patient’s health, just as the other risks I’ve
screened for are relevant. The vast majority
of patients are entirely willing to talk about
firearms with their providers when they feel it’s relevant
to their health or the health of someone in their home. If the patient I’m seeing
has none of the risk factors and is not at risk
because of someone else, I personally don’t
ask about firearms. I screen for firearms when
there is a specific indication. You might choose to
screen more generally. If a patient is at risk of
injuring themselves or someone else and they have
access to a firearm, there are several important
follow-up questions to ask about. Who can access the firearms,
how the firearms are stored, and who the firearms belong to. This will help us
assess the level of risk and determine how
best to counsel the patient to reduce risk. Knowing who has access and what
the current storage practices are will help you make concrete
recommendations for reducing the risk of injury or death. Finding out who owns the
firearms is important so we can get a sense of who
makes the decisions about how they are stored
and what potential we have to ensure those
storage practices are safe. When we’re planning a
counseling approach, we’ll obviously want to be
ready to answer the patient’s questions about firearms. This could include questions
about how to store firearms safely, what to do if a patient
is worried about someone else’s firearm access, how to address
firearms and safe storage in other homes where the
patient’s children spend time, and where to learn more about
firearm laws in your state. Our recommendations
regarding firearms will vary from
patient to patient. If I learn from a patient that
not all firearms in the home are stored securely, but
that no one in the home is going through a tough
time or a period of crisis, I simply aim to discuss safe
firearm storage options, and then plan to follow-up
at the patient’s next visit. Let’s take a look at what
safe firearm storage means. Store firearms unloaded. Store firearms and ammunition
locked up and ideally separate from each other. Assume that children know
the location of firearms and ammunition in the home. And keep the keys
or combinations to firearm-locking devices
inaccessible to children and other high-risk people. There are a variety of safe
storage devices for firearms, and the right one
for each patient will vary depending on what
type of firearms they own and the reasons for
owning those firearms. Let’s walk through a
few different devices firearm owners can use to safely
store a semi-automatic pistol, a common type of handgun. Before locking up
a firearm, it’s important to know
that it’s unloaded. To do so, first remove the
magazine, then open the slide, and make sure there isn’t
a cartridge in the chamber. A cable lock is the most
inexpensive and widely available type of
locking device. In some areas, cable locks
are given away for free by law enforcement agencies. While cable locks may
not prevent theft, they can prevent unauthorized
or accidental use of a firearm. To use a cable lock, first,
lock the action of the gun open. Then, put the cable
through the magazine well and out the ejection port. Finally, lock the cable
and remove the key. At this point, the pistol cannot
be loaded, nor can it be fired. Another inexpensive locking
device is a trigger lock. Before using a
trigger lock, make sure the firearm is not loaded. To use a trigger lock,
first separate the lock into two pieces. Insert the cylinder through
the trigger guard behind the trigger so that
it cannot be pulled. Then, attach the second
piece and lock the device. Similarly to cable
locks, trigger locks may not prevent theft. But they can prevent
unauthorized users from firing a firearm. Another safe storage
device is a lockbox. Lockboxes are more expensive
than trigger locks and cable locks, but they may better
protect against theft and they keep
firearms out of sight. A lockbox is a small safe
which locks a handgun inside using a combination,
keypad, key, or biometric or fingerprint technology. Firearms stored in lockboxes
should be stored unloaded. Many lockboxes come
with a security cable that allow you to anchor
them to a secure fixture. Firearm owners may opt to use
a firearm safe to safely store firearms. They may accommodate multiple
firearms and firearms of various sizes. To use a firearm safe,
be sure that all firearms are unloaded before
placing them inside. Then, lock the safe with
a combination, a keypad, or biometric technology. Ammunition should be stored
separately from firearms and also locked up. Be sure to keep the keys
and combinations to firearms safe storage devices away
from all unauthorized users. Some storage devices that
are suitable for long guns, like rifles or shotguns,
look a little different, but they generally
function the same way. Remember, if you learn that
there are firearms in the home but no one is at risk, you
can use your counseling to promote safe storage
using devices like the ones we’ve just seen. I might learn during the
course of my normal questions about risk that someone is at
extreme risk of firearm injury or death. To keep the patient or
others in the home safe, I might decide to make
referrals to social services, mental health
services, or programs for patients with
substance-use disorders. The patient or their family
may need specific counseling on how to reduce access
to firearms while they are at highest risk. And in certain
circumstances, I may need to contact local law
enforcement or the patient’s family. No matter where you work,
HIPAA regulations expressly allow disclosure of ordinarily
confidential information when a person is at imminent risk. In situations like
these, we can recommend that firearms be temporarily
stored outside the home. This might be available
on a voluntary basis at gun stores, shooting ranges,
or local law enforcement agencies. And in some states, firearms may
be stored with trusted family members or friends. An increasing number
of states allow for gun-violence
restraining orders, also called extreme-risk
protection orders, which allow for firearm
recovery by law enforcement under specific conditions
involving an imminent threat. As providers, we should be
sure to know what options are available in our areas. Putting time and space between
a person in crisis and firearms can be lifesaving. Consider the following scenario. An older male visits
his primary care doctor for a routine checkup. In conversation, his
primary care doctor learns that the
patient is depressed and drinking more than usual. His wife has
recently passed away. He reports having reduced
social interaction. In this case, the provider
requests a psychiatric consult. You might be comfortable
caring for this case without a consultant. Let’s see what happens. So Mr. Johnson, what brings
you here to see me today? I don’t know, maybe depression. My wife died recently. I really miss her. I’m kind of on my own now. And work isn’t going too well. And I’m drinking too much. How much do you drink
on an average day? Few beers– I don’t know–
maybe a six pack, maybe more. Some people with depression
find that drinking makes their depression worse. Do you ever find when you’re
drinking that you feel more sad and you get down in
a really bad place? Yeah, I guess so. I mean, I don’t feel
that way now, but– How far do you ever get
into that dark place? Do you ever think about
actually ending your life or have you taken
steps to do it? Yeah, I have some
guns at home, and I thought about doing
something with them. Let’s talk about your guns. What do you have at home? Well, hmm. I hunt, so I have a couple of
shotguns, a couple of rifles, and a handgun for target,
and one to defend myself. And I just keep it
in the nightstand. Sounds like you always have
one loaded and pretty close at hand. And you say you
want to live now, but do you ever worry that
you might feel differently? Sometimes, I, when I’m drinking,
I get into a pretty dark place. Is there a safer place
you could keep your guns, like maybe a friend that you
could give them to until you’re feeling a little bit better? Oh, I’d I need them
for protection. I need my gun. I mean, I hear that,
but as your doctor, I actually think that
your guns are making you a lot less safe right now. I’m really worried you might
go home, be by yourself, start drinking, have your
depression get worse, and maybe you’d use
one on yourself. And that’s the kind of
decision that you don’t get a chance to rethink later. Can we talk about ways to
prevent something like that from happening? I don’t want to be one
of those one those people we can’t have a gun
the rest of his life. I don’t think that’s
necessary, but I do think it’s really
important right now, with your circumstances,
to put some time and distance between you and your guns. I think you’re right. I’m glad we’re on the
same page about this. When you’re counseling
a patient who’s going through a tough time
and has access to firearms, the approach you
take to counseling might be especially important. You can emphasize
that your aim is to make the patient
safe in the short term until the crisis passes. In cases like the one we just saw, we’re concerned about high risk of suicide with both the impulsivity of attempting suicide and the lethality of firearms in mind. Temporarily storing firearms outside the home can be a good way to increase safety. After you’ve made recommendations to patients, whether or not it’s an extreme risk situation, remember to follow up. Find out whether the patient acted on your safe firearm recommendations and why or why not. Remember that circumstances change and that means risk is not static. We’ve created materials for you to use in a clinical setting. The handout for providers details considerations for evaluating risk and tailoring the firearms conversation for each patient. Send the patient handout home after you have had the firearms conversation as a reminder of why firearms in the home are risks and what they can do to reduce risk for everyone in the home. The handouts are available on our website. While it’s important to understand the policies in our states that might be relevant to discussing firearms with our patients, we can be very clear that you can ask. There are no state or federal statutes that prohibit us as providers from asking our patients about firearms when it is in the interest of their health and safety, or the health and safety of someone living or spending time in the patient’s home. You might have heard of so called gag laws, particularly in Florida, where the Firearm Owner’s Privacy Act was widely misinterpreted as preventing providers from asking about firearms. That law, however, specifically permitted a provider to ask if the provider, and I’m quoting here, in good faith believes that this information is relevant to the patient’s medical care or safety, or the safety of others. And it’s no longer on the books. In 2017, it was declared an infringement of freedom of speech and overturned by the US Court of Appeals. The Affordable Care Act includes language on asking about firearms, only to the extent that it prohibits required collection of firearms information by wellness and health promotion programs. So not only can we ask, but when necessary we can disclose the information we receive and we can intervene. The HIPAA privacy rule says that a patient’s health information may be disclosed when “necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public” and when the disclosure is “to a person or persons reasonably able to prevent or lessen the threat.” This disclosure can, when relevant, include information about firearms. Imminent is not precisely defined but in studies of violence, it is often taken as meaning anything from a few days to months. Elsewhere in the code of federal regulations, an imminent hazard is one that can cause harm before a federal regulatory agency is able to take formal action. When there is a serious and imminent threat, we can intervene. Many states, including 8 just in 2018, have enacted policies for recovering firearms from their owners when the owner has demonstrated extreme risk. These are commonly called extreme risk protection orders, or gun violence restraining orders, and elements of the policies vary from state to state. Extreme risk protection orders are civil court actions and can be used in cases in which an individual has exhibited dangerous or threatening behavior, has access to firearms, and isn’t otherwise prohibited from having them. We’ll use California as an example. In California, GVRO procedures are based on those used for domestic violence restraining orders. To get a GVRO for someone, a petitioner, who can be a law enforcement officer, an immediate family member or a household member, must file a petition presenting evidence for why the respondent is an imminent threat to self or to others. A judge reviews the petition, and if the order is granted, firearms can be recovered for up to three weeks. During those three weeks, a judge can hear the case and decide whether to extend or cancel the order. When the order is canceled or expires, the respondent can request to reclaim his or her firearms. These protective orders do not affect individuals’ abilities to own or purchase firearms in the future, as long as they are not otherwise prohibited from doing so. There are encouraging results from Connecticut and Indiana, which have had similar policies in place since 1999 and 2005, particularly regarding suicide. Both state’s researchers estimate that a life is saved for every 10 orders issued. That’s a number needed to treat of 10 for preventing a patient’s death. Though in most states as providers, we can’t petition for these types of orders, we can let law enforcement or family members know if we think there’s imminent risk and intervention such as this is necessary. Resources that can help with understanding state firearm laws include the Giffords Law Center, and the RAND Corporations’s new state firearm law database. It can be important for us to generally know our state’s policies, and to be able to point patients toward the state’s firearm policies if they ask. There are challenges to counseling. Even though providers appear to overwhelmingly feel it’s within our scope of practice, and it’s relevant to the health and safety of at-risk patients and their loved ones. Time may be the biggest challenge. I certainly feel time pressures when I’m at work. But remember, we’re not recommending universal counseling. We’re recommending that when risk factors are present and firearm access is directly relevant to the health of a patient or someone in the patient’s home, you take the time to talk about it. It can be a brief, nonjudgemental, collaborative conversation with concrete recommendations to reduce risk. Another common barrier is that you might be uncomfortable asking. If this is the case, consider all the private and sensitive questions you’re accustomed to asking patients. About their personal habits, their drinking and drug use, their sexual history. Plan your approach and practice the questions about firearms to make sure you’re comfortable in the exam room when you’re speaking with an at-risk patient. You might believe you don’t know enough about the topic. We’ve heard this often. Historically, providers haven’t been trained to evaluate risk for firearm injury or counsel on firearm safety. We’re working on this though. More and more research, and more and more funding, is being put into understanding firearm injury and death from a health perspective, and developing targeted interventions, including clinical interventions for firearm injury prevention. And for now, there’s the What You Can Do initiative and other resources on the provider’s role in preventing firearm related harm. You can join thousands of other providers across the country in making a public commitment to counseling your patients. Visit the article “What You Can Do to Stop Firearm Violence” at Annals or Internal Medicine online. Click “make your commitment now.” We vary widely in our experience with firearms and our opinions about them. But I suspect the great majority of us have had clinical experience with firearm injury or its consequences. It’s this common experience of treating the victims of firearm related harm that reminds us of the importance of prevention. Healthcare providers have a unique role. You are committed to your patient’s health and you have opportunities every day to talk with patients about risk and safety. Prevention is the best strategy here. Remember that most of those who die from gunshot wounds do so at the scene of the shooting. There’s no opportunity to intervene once the injury has occurred. Survivors’ lives are often irreversibly altered physically, psychologically, emotionally and economically. The following professional organizations have issued statements on firearm violence as a health problem. Their logos appear here with permission. If you’re looking for more information on firearm injury and death, epidemiology interventions, patient receptivity, identifying risk factors or planning a counseling approach, you can find many of the answers on the What You Can Do initiative website. And if you can’t find your answer there, please send us an email and we’ll help you out. Thanks for watching. We hope to hear from you as you make a commitment to asking about firearm access when risk factors are present and counseling your patients when indicated. Please let us know how it is going and what we can do to help. Thank you. Support for the University of California Davis Violence Prevention Research Program comes from the Heising-Simons Foundation, the Fund for a Safer Future, the California Wellness Foundation and the Joyce Foundation. Support for UCFC, the University of California Firearm Violence Research Center comes from the State of California. [MUSIC PLAYING]

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