Aiming for Safety: Prevent Firearm Injury With Open Patient Conversations

Editor’s Note: James Bigham, M.D., M.P.H., FAAFP, is a clinical professor in the Department of Family Medicine and Community Health at the University of Wisconsin School of Medicine and Public Health.  He was named the 2024 Family Physician of the Year by the Wisconsin AFP, in part, for developing firearm safety and suicide prevention training programs for students and clinicians that emphasize respectful, informed conversations with patients. He recently co-authored an AFP article regarding prevention of firearm injuries.

Sanjay Batish M.D., FAAFP, is the owner of Batish Family Medicine in Leland, N.C., and a former scholar in the AAFP Foundation’s Family Medicine Discovers Rapid Cycle Scientific Discovery and Innovation program. He has submitted a manuscript for publication entitled “Screening for firearm violence exposure in 14- to 24-year-olds in primary care.” Additionally, he recently completed the first analysis in North Carolina assessing the impact of gun shows on rates of firearm fatality and injury.

Dr. Bigham is presenting a related clinical skills session during the AAFP’s Tough, Taboo and Trending Topics in Family Medicine livestream, March 25-28. Both family physicians are presenting related clinical skills sessions Oct. 5-9 during the Family Medicine Experience in Anaheim, Calif.

A national patient survey found most patients, including gun owners, believe that clinician-initiated discussions about firearms can be appropriate, but many physicians have not been trained how to counsel patients about firearm injury prevention.

Here’s a case example that demonstrates the benefits of a family physician counseling patients and families on firearm harm reduction respectfully and effectively:

MW is a 45 y/o man with a PMHx of anoxic brain injury in 2010. His functional capacity is that of a 12-year-old. He lives with his father, who is his sole caregiver. During an annual physical exam, he and his father were asked about firearm access and storage patterns. MW’s father communicated that he owned three firearms, and all were loaded and easily accessible. Brief counseling regarding the potential harm that could occur if MW accessed a firearm resulted in the father enthusiastically accepting free cable locks to keep all three firearms secure. During a routine follow-up 6 months later, MW’s father volunteered that he was using the cable locks. He felt good that by having secure firearm storage he was creating a safer home environment for his family.

How did we get here, and what was the key? We routinely engage our patients in dialogue about firearm injury prevention, and you can, too.

Every 30 minutes someone in the United States suffers a firearm-related death and two to three people are injured by firearms. These numbers can feel daunting. However, the CDC encourages us that “firearm injuries and deaths are preventable — not inevitable — and everyone has a role to play in prevention.” 

All of us as family physicians are well positioned to screen and counsel on this important public health issue by coupling our clinical expertise with cultural humility.

Patients Are Willing to Discuss Risk Reduction

Some of us worry that asking patients about access to firearms will be perceived as intrusive or politically motivated. We get it. And yes, we have had patients push back. However, we find patients are open to the discussion when we’re tactful and transparent about our motivation, which lines up with research done at the VA and published in 2021 and 2023. These are the keys to such conversations:

• explain that the conversation is about keeping the patient and their loved ones safe,

• respect the patient’s autonomy and

• speak nonjudgmentally.

We also find that patients are more receptive to terms such as “responsible firearm ownership, use and storage” and “secure firearm storage” rather than “safe storage.”

We’ve learned the value of letting our patients teach us about their expertise and experiences. Understanding why they own a firearm helps us tailor individualized plans for harm reduction.

How Do I Start Talking About Secure Firearm Storage?

One place to start talking about firearm secure storage is during routine pediatric visits. The Bright Futures forms parents get before a well-child visit ask whether firearms are present in the places their children spend time. This provides a natural chance to ask simple follow-up questions: “How are your firearms stored?” “Do your children know how to access them?”

These discussions are also an opportunity to encourage parents and guardians — whether or not they own firearms — to ask about firearms in other homes where their children play. We find many parents appreciate brief coaching on how to handle these pre-playdate questions without coming across as prying or judgmental by using straightforward questions such as, “What’s the plan to make sure the kids don’t have access to your firearms?”

Turn Routine Screening Into Talk About Plans

You have another natural opportunity to ask about firearm injury risk when you talk to patients with mental health conditions.

Most firearm deaths in the U.S. are due to suicide, so even before a patient with a mental health condition might disclose suicidal ideation, we ask if they have a plan should they ever feel unsafe having access to firearms due to issues such as their own mental health or having an at-risk individual in their home.

We share with these patients the idea of asking a friend or family member to securely hold their firearm until they no longer feel concerned about having access themselves. Many areas also have Gun Shop Project programs where local gun shops will hold firearms for free or at a low cost. As you get engaged in this work, you may want to see if your local gun shops participate in this program.

Learn More About Preventing Firearm Injury

Dr. Bigham, who recently co-authored an American Family Physician article on office tips for preventing firearm injury, will be presenting related clinical skills at the AAFP’s Tough, Taboo and Trending Topics in Family Medicine Livestream March 25-28. And we both will be presenting at FMX Oct. 5-9 in Anaheim, Calif. We would love for you to join us for one of those sessions because we want to collaborate with you. 

If you want to learn more in the meantime, we recommend these free online resources:

• Reducing Gun Violence in America: Evidence for Change;

• The BulletPoints Project, which has clinical tools for preventing firearm injury;

• Clinicians and Firearms from Scrubs Addressing the Firearm Epidemic; and

• the 2024 Surgeon General’s Advisory on Firearm Violence which provides a helpful overview with up-to-date national data and a public health focus.  

Thank you for the work you’re doing to care for your community. We’re eager to learn from other family physicians who are engaged in firearm injury prevention and would like to comment on this post about your experiences including effective strategies you employ and any specific challenges you’ve faced. We are also hoping to create a list of family physicians working on firearm injury prevention work. If you would like to collaborate, please consider joining our interest group by completing this form.

We recognize the importance of approaching this sensitive topic with empathy and understanding. By providing compassionate, culturally aware screening and counseling, we can empower our patients to make informed decisions that prioritize injury prevention. We look forward to working together to help reduce the risk of firearm injury for our patients.