Practice good medicine, go to jail

Jan 24 2011 Published by under Medicine

A Florida legislator wants to imprison doctors for practicing good medicine.  "Really?" you ask.  Is this another anti-abortion bill?  Assisted suicide?

No, it's about guns. It is the policy of my professional organization and many others to inquire about firearm ownership and safety.

Is this a valid position, and if so, why?

Physicians are charged with prevention and treatment of human disease/injury. Prevention encompasses screening for risk, and preventative treatments such as vaccination. It also includes counseling regarding important health behaviors, such as seat belt and helmet use.

Are firearms an important, preventable health problem?   If so, how do we intervene to prevent firearm injury and death?

The data regarding firearms and preventable injury is unassailable. The CDC and DOJ both track statistics, but as an example, homicide and suicide by firearm are the second and third leading causes of injury-related death in the US in the 15-24 age group. The exact magnitude of the problem can be debated, but its health significance cannot.

The American College of Physicians (in a 1998 position statement) has taken a two-pronged approach: asking patients about gun ownership and safety, and advocating for gun-control legislation. The first should be uncontroversial---who can argue with asking a patient if they own the means to end life rapidly and violently, if they know how to secure it properly, and if they keep it out of the reach of children?

The second point is, needless to say, very controversial, although not so much among physicians, who consistently poll favorably on the issue.

Lets add some science-based medicine to the cauldron. Is it plausible that doctors' interactions with patients and legislators can reduce gun violence? Certainly.  To what degree can we physicians help reduce gun-related injuries?  Studies have shown variable efficacy of firearms safety counseling in changing patients' behavior.  Can this intervention cause harm?  It's hard to see how.

Given the extent of the problem, even a small positive effect on patient behavior can have a large impact.  The only negative outcome is having a patient ignore your advice.  Most patients understand that the doctor has their best interests at heart, and that recommendations come from data rather than ideology.  I don't tell my patients that the must remove guns from the house, although I do point out that they are statistically likely to be safer without them.  I do recommend that they practice safe storage of firearms.

So what about this proposed law? What does it say?

1)(a) A verbal or written inquiry by a public or private physician, nurse, or other medical staff person regarding the ownership of a firearm by a patient or the family of a patient or the presence of a firearm in a private home or other domicile of a patient or the family of a patient violates the privacy of the patient or the patient's family members, respectively.

(b) A public or private physician, nurse, or other medical staff person may not condition receipt of medical treatment or medical care on a person's willingness or refusal to disclose personal and private information unrelated to medical treatment  in violation of an individual's privacy as specified in this section.

(c) A public or private physician, nurse, or other medical staff person may not enter any intentionally, accidentally, or  inadvertently disclosed information concerning firearms into any record, whether written or electronic, or disclose such 43 information to any other source.

A violation would be a third degree felony and could be punished with a fine “of not more than $5 million if the court determines that the person knew or reasonably should have known that the conduct was unlawful.” As the Palm Beach Post reports, the NRA has identified the bill a priority item on its agenda for this Florida legislative session. The legislative proposal would clearly invite a strong challenge as an unconstitutional prior restraint if enacted.

This is, in technical terms, a steaming crock of feculent idiocy (and, I would think, unconstitutional).  For a legislature to decide what a doctor and patient may not talk about is a profoundly unconservative idea.  What if the junk food industry lobbies a legislator next?  No more proper counseling for my diabetics?

Even in the current insane political climate, I doubt this bill would pass or stand. But for someone to propose it, and for a major lobbying body (the NRA) to support it is equally sad and dangerous.


*One wonders what the Official Club for Wingnut Doctors would think of this proposed bill.

24 responses so far

  • William Wallace says:

    By comparison, millions of people are injured each year after unintentionally falling, being bitten, getting stung by bees, etc. This is a huge strain on our health care system. Xrays, scans, MRIs. Yet MDs aren't routinely asking if their patients are wearing their helmets while training for a triathlon, or if they know the proper way to lift a heavy objects.

    Doctors should stop worrying about behaviors. It's difficult enough to get 5 minutes alone with a doctor. If they want to make political statements, they can go buy a bull horn and stand out on a street corner shouting "wear your seat belt, sell your guns, don't repeal ObamaCare." That is--if they have enough time one 40,000,000 more new patients seeking free appointments every time their noses gets stuffy doesn't keep them busy.

    • WhizBANG! says:

      Actually many PCPs do ask about seatbelt and helmet use, fall prevention, and other "behavioral" anticipatory guidance. The American Academy of Pediatrics has a full volume of stuff to address at well child visits since these are the things that hurt and kill children.

    • James Sweet says:

      Heh, Wallace, you sounded fairly sensible over on Good Math/Bad Math -- now you are painting "wear your seat belt" as a "political statement"? Dude... Really?!?

      I recognize that there could be legitimate controversy over seat belt laws, especially for a someone of a libertarian bent like yourself. But the advisability of wearing one's seat belt? How is that political?

      • William Wallace says:

        You mean, other than seatbelt laws, seatbelt campaigns, and no seatbelt as a primary cause for a pullover, how is it political? You got me.

        But I think I complained about doctors prying into behaviors, especially in areas with political overtones. It's been a pet peeve of mine for several years. Now, PalMD might not mind what follows, but suppose a patient council was advising its members to inquire into their own doctors behaviors:

        1. Do you abuse pain killers?
        2. Do you wash your hands before seeing each patient?
        3. Have you ever had an inappropriate relationship with or made an inappropriate sexual advance toward a patient?
        4. Have you ever been the subject of a state board of medical practice investigation?

        I imagine many doctors, if patients suddenly broadsided them with such questions, would feel uneasy, especially if they weren't aware of the patient council’s recommendations. And, how much funnier would it be if half your patients, upon your entry into the exam room, whipped out a questionnaire with various versions of these questions, in random order, and asked the good doctor to fill it out before proceeding.

        If, after tapping on my liver, my doctor asked about my drinking habits, I can see the connection. But if I come in for a sinus infection, I don't want any prying questions regarding gun ownership, seatbelts, or the use of headphones while jogging in urban environments. If such questions are necessary in the treatment of the sinus infection, the good doctor might want to get a bedside manner and explain why he is asking if, for example, I smoke. If he is just blindly running through a checklist of boilerplate questions, I'll not only pass, I'll lecture the doctor on his uncouth prying. (And I have done exactly this, on exactly the issue at hand, to my own doctor).

        • skeptifem says:

          You do realize that patients don't have to disclose anything though, right? Patients lie all the time. If you are so darn paranoid about it don't answer the question or lie about the answer. If you want some medical advice on gun ownership then tell the truth. I don't know why you think there should be rules about what physicians can ASK when the most serious possible result is the physician SUGGESTING something back. The role of the physician in society is to improve the health of people, don't forget that. They aren't like a mechanic, they have a social obligation attached to the profession.

  • Joseph j7uy5 says:

    Under what circumstances would it be appropriate to prohibit physicians from asking about alcohol use? Obviously none. Another point: under the law as proposed, it would be entirely possible for physicians, especially psychiatrists, to face a dilemma: exposure to civil liability, for failure to prevent suicide or homicide, or exposure to criminal liability, for asking about firearm possession.

    But in a way, I dislike even making this comment, for fear of dignifying a preposterous proposal.

  • William Wallace says:

    Also, regarding the records, this is critical. With medical records going digital, and with third party record maintainers maintaining records for hundreds if not thousands of offices (less expensively than an office could do on its own), and with state departments of health obtaining those records for "research purposes", what goes into a medical record is in fact a political question, like it or not. With large scale centralized medical records, if a Joe the Plumber asks an impertinent question, it is getting easier and easier for powerful interests to obtain embarrassing information (since you probably didn't care for Joe the plumber, consider: whether or not, or how many times, a president has had an STD, sought treatment for depression, etc.)

    • Jim says:

      So, then, you'd argue doctors can't ask about mental health conditions or addiction problems as well? Or erectile dysfunction or embarrassing halitosis or . . . where does your slippery slope end?

      Doctors need to be aware of things a lot more private than whether a person has a gun collection or not.

  • Nomad says:

    I just don't read this as being about outraged gun nuts that object to being given safety lectures. There's too strong an aura of paranoia about it. Violates the privacy of a patient? Doctors are supposed to essentially know our deepest darkest secrets. Our sexual behavior, our psychological tendencies, our diet, our moods... They might know things about our bodies that we don't know. The issue of privacy is a question of who may access the information that your medical professional is privy to, not keeping said professional selectively blinded.

    I'm running this over in my mind, and the only motivation I can figure for it is somewhat different. I think it's more about the sense of paranoia expressed by William Wallace here. A specific kind of paranoia. A specific kind of person who thinks that we're one step away from a one world government takeover. I'm not saying WW is either a card carrying member of the John Birch society or a pre-millennial dispensationalist, but he shows a similar instinctive fear of his name being entered into "the system". I'm talking about the kind of person who has fevered fantasies about using his private arsenal to protect his country from one world government domination. Such a person sees the new world order thugs using databases of gun ownership to track down firearms owners and take their weapons away from them. Hence the focus on records of gun ownership. I expect the same demographic is viciously opposed to any sort of gun registry.

    Looked at from the position of a comparatively sane and law abiding gun owner this law is just weird. To suggest that such a person is willing to, say, talk to his doc about the fact that his genitals have turned a funny color, but would consider it an invasion of his privacy to mention that the gun that he shot himself in the foot with was his own weapon makes no sense.

  • andre3 says:

    I think a better idea would be for conservatives to use personal choice to decide not to go to the doctor if they don't want asked about their guns. Obviously, health care is not a right for all persons of this country, and this would clear up the market for people who actually want a valid risk assessment of their life and lifestyle and provide more time for doctors to have good conversations with their patients.

  • daedalus2u says:

    I think nomad nailed it.

    “Looked at from the position of a comparatively sane and law abiding gun owner this law is just weird. To suggest that such a person is willing to, say, talk to his doc about the fact that his genitals have turned a funny color, but would consider it an invasion of his privacy to mention that the gun that he shot himself in the foot with was his own weapon makes no sense.”

    It only makes sense if, to these gun nuts, their guns are more important than their genitals. Confirming what us non-gun nuts have known all along.

    Does this mean that any “physician, nurse, or other medical staff person” would be unable to testify in court about firearms or firearms injuries?

  • daedalus2u says:

    Since asking about guns is the well established "standard of care", would malpractice insurance cover these fines?

    Couldn't this be just a cynical ploy to balance the Florida budget on the backs of health care workers and malpractice insurance companies?

    • OleanderTea says:

      The last sentence, though I can see why you'd think it a possibility, is unlikely. Historically, Florida prefers to balance their budget on the backs of the poor and disenfranchised.

  • James Sweet says:

    Huh, I've never had a doctor ask me if I had any guns in the house. At least not that I can remember. I'm also not sure if any have asked me about seatbelt use, although I probably just wouldn't remember that. I would remember if they asked me about guns though, I think.

    Seems like a sensible question though -- as you say, it fits in pretty neatly with a doctor's role to ask about that, and if so, make sure the patient knows how to secure them properly, etc. Why not?

  • OleanderTea says:

    Funny that, since in Florida (my home state), it's very easy to purchase firearms.

    Now that I live in Massachusetts, docs ask me if I have firearms in my home all the time. This ticked me off at first, but on thinking about it, I suppose it's all about context. If my shrink or chronic pain doc asks me, that's understandable. If my ENT asks me, that's ridiculous. I fail to see what a sinus infection has to do with firearms.

    When the question is asked by a doc with no need to know, I lie.

    • Dianne says:

      When the question is asked by a doc with no need to know, I lie.

      Might I suggest refusing to answer instead? Or even asking why he or she wants to know? There's nothing wrong with saying, "That's none of your business" and if your doctor's offended, that's his/her problem.

      • OleanderTea says:

        After thinking it through, instead of refusing to answer I think I'll offer to take the doc to the range with me.

  • Dianne says:

    I have an unsolicited ad from a hospital in Florida inviting me to apply to fill one of, apparently, several open positions at that hospital. I think I'll decline.

  • daedalus2u says:

    If you ever feel the need to lie to your health care provider, you should get a new health care provider.

    • Vicki says:

      Unfortunately, "get another health care provider" may be easier said than done: if a person has health insurance that few providers accept (anything from Medicaid to "this is the cheapest thing my start-up employer could find"), or lives in an underserved area (and/or has limited access to transport). Or if the would-be patient is in a group that doctors tend to scorn: if you're fat, you can go from doctor to doctor without finding one who will pay attention to any actual health issues (including things like broken ankles) rather than insisting on lecturing about weight loss. (And what should you do if your health care provider assumes you must be lying, because they cannot believe that you are exercising regularly and eating a healthy diet, because you aren't losing weight?)

    • OleanderTea says:

      "I only drink socially."

      "I always wear a condom."

      "But my kids get a balanced diet, we never give them junk!"

      "But I exercise three times a week!"

      "Sure, I've been following the low-fat diet plan! Mmmm, kale!"

      Everybody lies. It's just a matter of degree and kind.

  • (another) former academic says:

    As hinted at by the previous commentators, 'The only negative outcome is having a patient ignore your advice' misses the mark.

    It is possible for patients to be so alienated by questioning that they consider intrusive (perhaps especially if they feel their appointment has been rushed) that they decide to lie to their physicians and/or not discuss issues that are of concern, for fear of getting 'a lecture'.

    I suspect 'well baby' visits are particularly perilous given how defensive most parents feel about their parenting decisions. For example, see this discussion

    I absolutely agree that gun safety is relevant to health, but the manner in which physicians discuss it is critical.

  • Kelly says:

    It is not paranoia to be concerned about what doctors enter into your records. Health insurance companies have been known to deny coverage by spurious connections to things such as alcohol and drug use as "pre existing conditions." Who knows how they would interpret gun ownership into their lovely attempts not to cover health issues? In addition, I think the point that medical personnel should not be able to deny service based upon gun ownership is fine. Do any medical personnel actually do this though?
    However, stating that doctors cannot inquire about gun ownership is only outdone in ridiculous-ness by the felony penalty for any of this!

  • Silver says:

    Bitter laughter.
    Coming late to the party, after... 5 weeks on call (it's not as bad as it sounds, they almost never call)... for psychiatry...
    I am darned well going to ask about the presence of firearms in the home (and the car, and the garage, and the shed).
    Our hospital has had two eventual suicides by gsw in the past month, and my private practice has had one attempt and one completed.
    And I live in a smallish town near a medium city.

    Of COURSE it's clinically relevant, Florida, just like tobacco (and I don't doubt that TN/OH would have been trying to ban inquiries into tobacco use a couple of decades ago.)

    And, as far as William Wallace's "patient panel" concerns regarding abuse of pain killers and sexual contact with patients... funny thing, our licensing board, and our hospital and clinic credentialing agencies, go through questions just like that.
    And I've had patients challenge me with questions similar to that.
    I answer them. Honestly.
    What's the problem?