Brother blogger and good buddy Will clued me in to an interesting post by Ken over at Popehat. It’s about Florida’s appallingly stupid law that vaguely forbids doctors from asking patients about gun ownership “unless information is relevant to patient’s medical care or safety or safety of others.” Since the only reason to ask about gun ownership is to determine if it is relevant to the patient’s medical care, safety or the safety of others, this law is beyond meaningless. However, as it’s already been struck down by a federal judge and I can’t imagine Gov. Scott’s addle-brained appeal going anywhere, I figured commenting on it was moot. (It’s been a banner year for awful laws that restrict a physician’s freedom of speech, though, hasn’t it?)
However, there are several points that Ken makes that I think warrant a reply.
He starts the post with his recollection of a weird doctor and his weird questionnaire:
Back in 1980 or so, my parents decided to send me to a new doctor in town to address some youthful complaint or other. The doctor was youngish, well-qualified, and charismatic. He showed me into a consultation room, handed me a clipboard with a lengthy questionnaire, and told me we’d talk after I had completed it.
Then the questionnaire turned odd and uncomfortable and intrusive. It asked about masturbation. It asked about looking at pornography. It asked about thinking about sex, and the frequency of such thoughts. (I was an eleven-year-old boy. There was no box to check for “I think about it all the time. I think about it between the seconds.“) It asked about same-sex attraction. At this remove, more than 30 years later, I’m not sure if the questionnaire had a religious sensibility or some other purpose. I only know that I found it instantly creepifying, and dreaded the doctor who would ask such things coming back into the room to touch me. I couldn’t put it into words at the time, but it was clear that the doctor had a non-medical agenda — an agenda beyond determining if I had ulcers or diabetes or fungus or something.
I have a few thoughts about this, largely informed by my training in adolescent medicine. I know that questionnaires are all the rage in medicine, and are considered a handy way of collecting information quietly and efficiently. I detest them. Any question I want to ask, I ask myself directly. I believe there is a requirement in the state where I practice that we do appropriate developmental screening as part of well child checks (which, obviously, should be done in any event), but I generally just glance at the screening form and then ask the pertinent questions myself.
Neither having seen the questionnaire Ken remembers nor knowing the doctor, it’s hard to know quite why those questions were asked in that way. Assuming good intent on the doctor’s part (notwithstanding Ken’s skeeved-out reaction), this illustrates the pitfalls of a one-size-fits-all questionnaire. I can see maybe wanting to know the answer to some of those questions for any given adolescent, but giving them to a barely-pubescent 11-year-old was developmentally inappropriate at best. For young adolescents, I ask a few preliminary questions about interest in dating, introduce the notion that I’ll be asking more in-depth questions at later visits, and leave it at that.
But that’s not really the crux of Ken’s point. He goes on:
I believe that the push to have doctors ask patients about guns flows primarily from a political-interest-group-driven anti-gun agenda. I also believe it reflects an unbecoming ambition by some in the medical profession to become entrenched in broader segments of patients’ lives. None of my doctors have asked me, but if they did, my trust in them would be diminished, and if they failed to accept a polite “I’m not going to discuss that,” I’d find a different doctor. If a doctor wanted to fire me as a patient because of that answer, I’d consider myself lucky to know that the doctor is an ideologue whose political views outweigh his or her commitment to my care, and happily avoid him or her — as I would with a doctor who restricted patients based on their voting record.
I have serious problems with much of this, but I will start with the part I agree with. I concur that there is an unfortunate tendency on the part of some in the medical community to over-medicalize or pathologize aspects of society or human behavior that are not pathological and do not require medical intervention or supervision. Lord knows, my own specialty is hardly immune to this. I hope regular readers would agree that I have a healthy skepticism about such interventionist tendencies, and I certainly have no desire to entrench myself more deeply in my patients’ lives. (Believe me.) I try to give sensible, reasonable and good-hearted advice insofar as I think it will be helpful, but in general I trust my patients and their parents to make their own best decisions without any clucking from me.
Now, then. That leaves the rest. It is with all due (and very sincere) respect that I heartily disagree with Ken’s assertion that doctors ask about gun ownership because they have a political agenda. I don’t actually ask about it on a regular basis, but I consider that a deficit, not a credit. For my part, I have absolutely zero problem with responsible adults owning guns, and would not be in any way inclined to use my professional position to dissuade anyone from owning one. (I have some qualms with the relative ease by which assault weapons can be obtained, but that’s not the same thing.) Asking if a family has guns in the house has nothing to do with a political agenda, and everything to do with knowing safety risk factors for my patients.
I am having a hard time finding any recent data on firearm-related deaths in the United States, with most of what I can turn up at least a decade old. Perhaps the recent numbers are much lower, I can’t say. However, in 1994 22% of the 1107 reported firearm-related deaths in children were unintentional. When I ask if there is a gun in the house, I want to know if it is appropriately stored and locked, and that older children have been educated about gun safety. That’s it. Of course I have an agenda, but it’s not anti-gun. I have the same agenda that every medical provider should have, which is to know about her patients’ lives with regard to factors that might compromise their health and safety. If I ask about safety belts and childproofing, is it not of a piece to ask if there are unsecured guns? Am I not to be asking about any of this?
I could say the same about gun proximity and the risk of completed suicide. If I have a patient who has admitted suicidal ideation to me, and I know that firearms account for half of all completed suicides, is it not an important consideration in helping me assess my patient’s risk of killing himself that there is a gun in the house? It would diminish Ken’s trust in me if I were to ask about this risk factor for morbidity or mortality? No sermon, no attempt to get him to get rid of it, but merely asking? I must say I find that uncharacteristically quick to jump to an erroneous and unfair conclusion.
I grew up in a small, rural town where lots of people hunted, and I know that people can own guns safely and responsibly. I also remember when a teenage girl a few years younger than me was killed when one of her friends shot her by accident with a gun he had secreted out of his house. It reflects no ambition to intrude into my patients’ lives if I ask questions to ascertain whether their homes are like the former, or if they are increased risk of a situation like the latter. It merely indicates that I want to do my job well.