Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

A Response to “The 5A’s of Firearm Safety Counseling”


I counsel ALL patients about gun safety, instead of ASKING every patient if they have guns in their home.

“That’s none of your ****ing business!”


That was the response I got from my patient the day I stopped asking everyone, “Do you have guns at home?”


This encounter occurred about twenty years ago, but flashed back to me when I read “The 5 A’s of Firearm Safety Counseling.”  I explained to my patient that I was not opposed to guns, but to accidents with guns. I disclosed that I have guns in my own home. It didn’t help.


I could see by my patient’s body language and facial expression that the well had been poisoned. Whatever rapport I had been able to build over the past few years as his primary care provider was badly damaged, if not destroyed. How could this have happened? I had the best of intentions. I grew up in a blue collar family; he was a blue collar laborer. I hunt; he hunts.


Would it have gone better had I asked more in-depth questions:  How many guns? What kind of guns? Who owns the guns? Probably not. However, I believe that firearm safety counseling should be as mandatory a part of wellness counseling as seat belts, smoke detectors, sunscreen, and sexual risk avoidance.  This is, indeed, my lane.


Trust is a fragile thing

I’m not sure whether I was ever able to regain that patient’s confidence. But, he wasn’t the only patient who reacted, rather than responded, to my questions. Trust is earned and is a fragile thing in any relationship.


I have chosen to substitute “ALL” for “Ask” as the first “A” – I counsel EVERY patient about firearm safety in the home, even when they interrupt me saying, “No guns in my home.” Educating each patient takes a bit more time, but I reach everyone, including the gun owners who falsely answer “No” when asked about guns in the home.


In most sectors of our society, including gun rights and gun control, there are almost binary extremes of opinions. As clinicians, we need to look at such a divide in our culture like we look at a laceration in the skin: we must draw both sides of such wounds together, to promote healing and maintain health.


I do not want those who need firearm counseling most, those who keep guns in an unsafe manner, to recoil from the “Ask,” and have their defenses up and minds closed before we even begin the conversation. More detail can come after I show respect, earn trust, and then revisit wellness counseling in the future. In 1988, when I spent a four-week rotation on the AIDS unit at San Francisco General Hospital, had I plainly “Asked,” “Do you have unprotected anal sex with multiple male partners?” I would not have been embraced by patients, staff, or faculty. We should strive for no less success with firearm safety.


My routine wellness counseling goes something like this:


I tell all of my male patients, “You should examine your testicles once a month, feeling for lumps and bumps, the same way women have been encouraged to examine their breasts. It should feel smooth, like a peeled hard boiled egg. If you notice changes from month to month, then I need to know about that.”


For men over 50, I say, “there is controversy about prostate cancer screening. Some experts argue that you shouldn’t do it at all, while others still advocate the finger test and the blood test regularly. If you are the kind of guy with the philosophy in every other area of your life of ‘if it ain’t broke, don’t fix it,’ then you might want to skip it; if you are the kind of guy who says ‘better safe than sorry,’ then you should at least do the blood test, if not both.”


I tell all of my female patients, “You should examine your breasts once a month, feeling for lumps-and-bumps.  Do you know how? You should do this about the same time in your cycle each month. If you notice changes from month to month, then I need to know about that.”


I tell all of my patients, “You should wear seatbelts in the car, lap and shoulder belt both. You should have a hands-free-gizmo so that you aren’t texting while driving. You should have smoke detectors in your home, on every floor, and check the batteries when you change your clocks, spring and fall. You should have a carbon monoxide detector too.  Guns at home should be stored unloaded and locked, preferably in a gun safe. You should wear sunscreen when you’re outside, even when it’s cloudy, on any exposed skin. The energy from the sun that changes the color of your skin is the same energy that causes skin cancer. And you should wear helmets when riding bikes, motorcycles, ATVs, skis, skateboards, horses, or anything else you think about riding. Sex in our world today has risks and you need to be willing to bet-your-life on your partner. Lastly, if you use a smartphone, you should program it so that in an emergency, through a locked screen, it can be opened to reveal the medical information which you want a first responder or ED to know, like allergies, medications, medical problems, emergency contacts, your name, etc. For Androids, you can download something from the App Store and iphones have that functionality built-in, but you have to set them up for this to work. Now, do you have any questions, complaints, remarks, suggestions?”


Primary care is a marathon, not a sprint, or even a mid-length event. Just like when reviewing their systems with a patient, if you come upon a mood disorder and get the feeling that there’s something specific behind it, pushing the patient to disclose that they were sexually abused and haven’t processed their feelings yet is not going to promote health and help them recover. Talking with them again, in the near future, specifically about their mood, has a greater chance of success. If preventive health counseling uncovers some area(s) in which greater safety can be advanced, relating to firearms or anything else, then following up with the patient about it is likely to be more successful at actually promoting change than forcing your way in and alienating the patient altogether.