This attempt to "protect" second amendment rights tramples mightily on the first amendment! Organizations like the NRA that exist as advocacy groups for particular interests (in this case gun ownership) have no competence in matters of medical practice, and should not be allowed to make policy that affects the delivery of healthcare. They are welcome to express their opinions and concerns, but a legislature that takes up such a bill without adequate consultation with health care providers, not to mention a clear understanding of the benefits and risks of the legislation on the population is being extremely irresponsible. I don't have any data (and I doubt the NRA does, either) about the number of legitimate gun owners whose disclosure of their gun ownership or its inclusion in their medical records has resulted in a problem for them later, but I am certain it is negligeable. On the other hand, that the presence of firearms in the house raises suicide risk substantially has been shown in numerous peer reviewed studies whose results have been replicated consistently. Following this lead, there is practically no topic that could theoretically be legislated as off limits to physicians;it is a case of fanatisiscm, and I hope that other state medical associations reject out of hand similar proposals.

There are thousands of Home Health Nurses, Physical and Occupational therapist, and Clinical Assistants who visit the homes of patients who are homebound. They need the attention of health care staff. I am a Psychiatric Nurse who did Psychiatric Home Health patients for 5 yrs. It is a standard of care to ask the patient if there are firearms in the home. This is to prevent a mentally ill patient from hurting a family member, member of the community, or self. If the response is yes, which it usually is in Texas then you ask that all firearms be removed from the house and placed in a safe place where the patient does not have access. This is clearly not a violation of the patients rights, rather it is to protect the lives of anyone they come in contact with. This bill is ignorant of how many health care workers would be put at risk, hurt or killed.

I very much appreciate the astute points made by Susan Ward and Eric Dickhaus. We need more of such advocacy!--Best regards, Ron Pies MD

This is a misreading of the bill, and probably psychiatry.

First, the law reduces physician liability, not increases it. This is "information bias": assuming that knowing information is useful in itself, that it is the same as acting on information. Put bluntly: if you're not allowed to ask, it's not totally your fault; if you are allowed to ask, what are you going to do about it? Seriously, what? All you've done is noted on the chart at Visit 1 that he has a gun, and that you did nothing for the next 14 visits. This is exactly what happens at all those "well baby visits": pediatricians collect a gigantic amount of information, harp excessively on whatever happens to be their pointless favorite ("he has a prominent tongue thrust, you should have that evaluated") and ignore the rest, and give out amoxicillin as a form of parental valium.

Second, the science isn't on the side of the doctors:

"A gun in the home is 43 times more likely to kill someone known to the family than it is to kill someone in self-defense, according to the American Academy of Pediatrics (AAP)…. states with the most guns at home have suicide rates double rates of states with the fewest guns, and those suicides are often children.."

and I do not doubt it; but is there any reduction in gun deaths because doctors get to ask this on their routine screens?

Third: getting an answer to the question is not the same as knowing the true answer to the question. If he says no, then what? Phew? (Asking this question didn't prevent a patient from pulling a gun on me.) The clinical interview fails where it is most important; patients are accidentally/deliberately unreliable, and doctors use the information to excuse themselves. Docs would do well to adopt the old adage of the Navy Seals that I just made up: always assume the other guy is armed. And HIV+. And a lawyer. And etc.

Fourth, the intent of the bill is explicitly to prevent discrimination against gun owners from insurers and doctors. If you're worried that your HIV status will adversely affect your employment, imagine what "owns two 9mms"will do.

One might ask what value there is in a five minute lecture about gun safety given to a long time gun owner by a doctor whose entire knowledge of guns comes from Hardcastle & McCormick, especially when the whole visit is 7 minutes.

One might also be tempted to ask about any racial bias: do doctors routinely ask minority patients about guns? If they do, how strongly does the doctor push them on it? (Or does he write with great relief: "patient denied guns.")

Those outraged by the new law also seem to think that it is a free speech issue: "since when is the government allowed to tell me what I can or cannot talk to my patients about?"

And in this single aspect, they are absolutely correct and simultaneously completely oblivious: medicine is no longer a private matter. Medicine turned its gaze to society and became an arm of social policy, at the service of the government. Time to bone up on our Foucault.

The Last Psychiatrist
http://thelastpsychiatrist.com

Edward Teach, well said!!

Furthermore - these questions of "free speech"and privacy rights of patients, right to own weapons (and to be left alone about it ...) all are pertinent only because the patient-physician relationship has already been inappropriately invaded. Such questions would be rendered meaningless if patients believed they had a choice of which doctor they see, and if physicians and patients didn't live in constant fear of what the "grownups" (meaning, insurance companies and the government) might do if such information was documented in the record - instead, some patients who value privacy above safety would likely restrict their business to doctors who don't ask so many questions - other patients would likely place great value on physicians who tended to be very intrusive, interpreting such invasiveness as "really caring."

And of course everything in between.

Risk for violence is well known and accepted as not increased by virtue of "mental illness"not otherwise defined and without individual history being considered.
Dr. Pies offers thoughts, i.e opinions, only, of one psychiatrist, with absence of critical thought.
Should other "risks' be the concerns of the physician? Would you remove a depressed patient from upper stories of a house, bodies of water, belts, electrical outlets, etc.
In a crime ridden neighborhood should a homeowner with any diagnosis, the symptoms of which are controlled by medication and followed by a physician, be seen as so impaired as to be at the level of risk Dr. Pies suggests, and therefore be ordered to give up his right to self defense?
Spare us the well meaning but illogical social engineers.

I appreciate the concerns expressed by Michael Ganz, Edward Teach, and William Sauve, but I believe that, in some instances, they have reached fallacious, and potentially dangerous, conclusions.

First: the use of a "reductio ad absurdum"argument, such as that offered by Michael Ganz, will not protect the physician in the event of a failure to assess the patient's risk of gun-related violence. Obviously, there are an infinite number of possible risk factors that increase the probability of suicide or homicide (Does the patient keep poisonous snakes in the house? Are there tall buildings with unprotected balconies in the neighborhood? etc.) but some risk factors are far more lethal than others, and are universally recognized as such within the medical/psychiatric profession. One of these is gun possession, as a risk factor in suicide, homicide, and combined suicide/homicide. For more on this, please see the article "Firearms and Mental Illness" in Psychiatric Times, by forensic psychiatrist Donna Norris MD and Marilyn Price MD, Oct. 30, 2009). As these clinicians state:
"Access to firearms is an important factor for clinicians to consider in any risk assessment of suicidal patients. Miller and Hemenway report that "in 2005, an average of 46 Americans a day committed suicide with a firearm, accounting for 53% of all completed suicides."…All discussions with the patient and his or her family regarding firearms should be documented. When clinicians are doing a psychiatric examination of suicidal patients, they should inquire about the availability of firearms in the household. If a firearm is available, concerns about safety should be raised with the family and police. This is particularly true when children and adolescents reside in the household."

Regarding Edward Teach's claim that "…the [Florida] law reduces physician liability, not increases it…"-a sort of "If we don't ask, and they don't tell, the law will say that all is well" argument--I believe this reflects a misunderstanding of how litigation against physicians works in this country. Of course, in the end, physicians often "win" a frivolous law suit, based on various legal arguments-but that doesn't stop plaintiffs from initiating law suits and dragging the physician through the courts, even if the MD defendant ultimately prevails.

Now, to be clear: the current formulation of the Florida law does permit inquiries re: firearms when "…the information is relevant to the patient's medical care or safety or the safety of others…" That exception may sound quite reasonable, and evidently, it persuaded the Florida Medical Association, who ultimately went along with the bill. But the "exception" clause has not persuaded many Florida pediatricians, who believe such a law would still have a chilling effect on the thoroughness of the doctor's evaluation. According to National Public Radio

http://www.npr.org/2011/05/07/136063523/florida-bill-could-muzzle-doctor...

one specialist in adolescent medicine recently told a Florida Senate committee, "What if I have an adolescent who's been bullied, [but] who's not suicidal? I don't think, under the current bill, I'm entitled to ask him if there's a gun in the home, or if he's carried a gun to school, or if he's thinking of harming someone else with a gun."

Indeed, the "relevance" clause may actually put the psychiatrist/physician in a medico-legal "double bind". If he or she fails to inquire about gun possession because it is not deemed "relevant", and the patient goes on to commit some act of gun-related violence, the physician may be held liable for failing to ask the "relevant" questions. On the other hand, if the physician decides that a query about gun possession is relevant; but the patient believes otherwise and becomes angry about the "invasion of privacy", he or she could initiate a suit against the doctor, on the grounds that the gun possession query was not clinically "relevant".

To put it bluntly: the physician should not be constantly looking over his or her shoulder at how much legal risk is entailed in asking clinically-indicated questions about firearms! Obviously, the "gun" question will not come up when a patient presents in the ER with a sore throat, any more than an astute physician would do a rectal exam under such circumstances. But these judgments should be dictated by our medical training, not by misguided legislation that intrudes on the physician's freedom of speech, as well as on the privacy of the doctor-patient relationship. That "the patient-physician relationship has already been inappropriately invaded" and has become "an arm of social policy" is no argument for a law that merely worsens our profession's predicament. --Ronald Pies MD

An addendum to readers:

Psychiatric Times operates on the principle that readers leaving comments provide their real first and last names. Blackbeard the Pirate ("Edward Teach") seems an unlikely source of reliable information on forensic psychiatry. The relevant principle here, Edward, is called integrity.

Oh, yes--to the point about "information bias": obviously, merely inquiring about gun possession is not enough--taking appropriate action, commensurate with the clinical circumstances and risks, is also required. But if psychiatrists are cowed by Florida-type laws, they may not ask about firearms at all, and that will guarantee that, in many cases, no appropriate action will be taken. This is clearly no way to reduce our medico-legal liability.

Ronald Pies MD

People in the USA are IRRATIONALLYFEARFUL of the governments possibly taking away their guns- I have heard really intelligent people express this fear- that will never happen. What also will never happen- is people rising up in arms against their goverment- can you imagine some handguns against a B-2 Stealth bomber?
There are about 33 SUICIDES for every DEFENSE of one's home using a gun, thats 33:1. Therefore I assume that people IRRATIONALLY overestimate their chances of protecting their home with a gun- SUICIDE is a RARE event, protecting ones home against an intruder with a gun is EVEN RARER...
So if you want to have your gun, then great, but dont be surprised when your friend who you didnt think anthing was wrong with- kills himself with a gun- or when a mentally ill individual buys a gun without a hitch and goes on a rampage. Its the price of our irrationaly fears...

from Ron Pies, in reference to the Massachusetts Medical Society--

I am pleased to report the following development, following the annual MMS meeting last weekend:

"Delegates adopted a resolution [#405] that opposes legislative interference in the right of physicians and patients or parents and guardians to discuss gun ownership, storage or safety in the home. The resolution also opposes any legislative or regulatory limits on a physician's ability to take a complete history and document relevant portions of the history into the permanent medical record."

Wi
th reference to Susan Ward's comment, in Australia working as a Community Mental Health Nurse I was involved in assessing an independent elderly man living alone, presumably suffering from untreated depression. It was a routine call-out, a referral from a physician requesting an initial in-home assessment. No Hx or mention of fire-arms had been documented therefore questions of that nature asked at the door could understandably have been interpreted by the patient as being invasive, intrusive; it may have impacted on whether the assessment went ahead-in hind-sight though, it could have prevented a possible fatality.

There were no overt clinical signs of depression. Person invited myself in. It was only well into conversation when discussing any Hx of intent/plan/means to self harm that he said-in passing-that he had been out at the range all day-belonging to a rifle club/registered firearms etc
---Registered or illegal-as stated above-was not the issue---.

Asked about firearms being locked away and where; found firearms cupboard to be unlocked and open; stated-he was in process of cleaning same when i called and thought to show it to me-unloaded of course-as he now had it in his hands, continuing to clean-denying any suicidation whatsoever. He found the the situation amusing-I realized I'd walked into a power-play. Clinically depressed?..... Definitely some undesirable personality traits.

Had the physician questioned his patient with regards any intent to self harm? was there a plan? did he have the means to carry this out? Had I thought to clarify with the physician if the patient had access to firearms, as there was no reference to this in the referral letter?

Needless to say the incident became one of high importance in terms of occ/health and safety on RTW, Monday.
Policy and procedures r/t to every aspect of patient referrals for in-home assessment were reviewed......as was physician/nurse documentation.

Apologies for the extended comment on what is an anecdotal reference to an incident outside the US-not affected by the legislation discussed here. I guess I wanted to/or had a need to share-as a nurse-not a physician-what it is like on the front-line, in a person's home with unexpected fire-arms present: an unforgettable
learning ex
perience, one though that myself. the organization, the physician and hospital involved undoubtedly learned from.

My thanks to Tash Rose for reinforcing the point made by Susan Ward--that the Florida law could have an adverse effect on the safety of many thousands of mental health workers and clinicians who make home visits, evaluate families involved in domestic violence, etc. --Ron Pies MD