How to Encourage Pediatricians to Ask Families About Gun Safety

There are personal and professional barriers that block pediatricians from addressing gun safety in their patients' homes.

Pediatricians are less likely to ask about home gun safety than other safety concerns, recent research indicates.

Guns are a leading cause of death for American children. For Americans aged 10 to 19, the rate of suicide by guns has increased since 2008. There are about 4.6 million children who live in homes where at least one firearm is stored loaded and unlocked.

The recent research, which was published in JAMA Pediatrics, compared child-well visit questions about gun storage and smoke alarm safety in patient homes. The questions were programmed into a university health care system's electronic health record simultaneously in January 2016.

For firearms safety, there were buttons in the EHR to indicate whether firearms were stored in a gun safe or locked cabinet, and whether they were equipped with trigger locks. There were adjacent buttons for smoke alarm safety, which indicated whether there were functioning smoke alarms in a patient's home.

Data was examined from more than 16,000 well-child visits with medical residents and faculty members from January 2017 to June 2018. The researchers generated several key data points:

• Smoke alarm queries were documented in 77.9% of the well-child visits.
   
• Gun queries were documented in 53.8% of the well-child visits.
   
• The rate of gun queries declined significantly among residents after the October 2017 mass shooting in Las Vegas, Nevada, and the February 2018 mass shooting in Parkland, Florida.

"Despite EHR cues, queries were less likely for guns than smoke alarms," the researchers wrote.

Interpreting the data and influencing clinician behavior

The lead author of the research told HealthLeaders that psychological factors likely played a role in the gun safety query reductions after the mass shootings in Las Vegas and Parkland.

"Avoidance is a common response to trauma. In fact, avoidance is one of the criteria that defines post-traumatic stress syndrome. A mass shooting is a shared traumatic community event, and the residents may have avoided talking about gun injury to protect themselves or the parents from thinking about the event," said Carole Stipelman, MD, MPH, medical director of the University Pediatric Clinic in Salt Lake City, Utah.

There are personal barriers that impact whether clinicians asked parents about gun safety, she said.

"Smoke alarms are noncontroversial, and physicians are familiar with them because they have them in their own homes. Medical training does not include education about gun safety options and physicians may lack confidence in discussing these devices with gun-owning parents. Physicians should be taught to speak about trigger locks and biometric gun locks with the same confidence as discussing other safety measures."

There also are professional barriers to overcome, Stipelman said.

"Clinicians may be uncertain about how to begin the conversation without appearing intrusive. The well-child check-up schedule is frequent—12 visits are recommended in the first three years. To be effective, these visits require maintaining a strong bond of trust with the family. Some clinicians may lack confidence about their ability to talk about keeping children safe from guns without damaging this trust."

Gun safety should be included in medical school training, she said. "Medical school education should include training to discuss gun safety in the home with a collaborative approach that preserves trust in the pediatrician-parent relationship."