Monday, May 09, 2011

Those Privacy-Invading Pediatricians, Silenced!

A while back, Roy blogged about proposed legislation in Florida that would make it illegal for physicians to ask patients if they own guns. What the??? Since when do we legislate what people can ask each other, outside of discrimination issues for jobs? And is there any precedent for legislating the conversation that occurs between a doctor and patient? So apparently this is going to pass, and Greg Allen writes in "Florida Bill Could Muzzle Doctors on Gun Safety,"

Florida Gov. Rick Scott is expected to sign a bill that will make the state the first in the nation to prohibit doctors from asking patients if they own guns. The bill is aimed particularly at pediatricians, who routinely ask new parents if they have guns at home and if they're stored safely.

Pediatricians say it's about preventing accidental injuries. Gun rights advocates say the doctors have a political agenda.

Ah, it's not about us shrinks, it's okay to ask if there is a question of danger. It's about the pediatricians. Personally, I think the pediatricians should fight back: if they can't ask who owns a gun and target their gun safety remarks, they should give extensive gun safety instructions and literature to every parent at every visit. Perhaps as a statement of unity, all pediatricians in all states should discuss gun safety with every patient, no questions asked.


Anonymous said...

I'm of the opinion that everybody should really have at least a basic knowledge of gun safety anyway. I suppose it would be too much to hope that those advocating this bill would be hoping that exactly what you're proposing might happen? (Is it delusional imagine that politicians might do something sensible? ..don't answer that.)

Meg said...

Actually, it's not a bad idea for pediatricians to address the issue of gun safety with all kids and all families.

There was a very sad incident in our area last winter where a 12-year-old was visiting a friend. They started playing with a gun they found in the house that belonged to the father of the host kid. The guest kid died.

The victim's parents were immigrants from a culture (Russia) that would never permit private citizens to own guns. They probably did not imagine that their son's friend's home could have a gun, and likely did not give him any warnings about the danger of such things.

The pediatricians around here probably knew enough to advise the parents and kid.

Anonymous said...

What's next? Are the tobacco and alcohol industries going to lobby for legislation barring physicians from asking if we drink or smoke? And, more seriously, what are the possible implications for psychiatrists or other physicians who have a serious concern that a patient is suicidal? If s/he expresses intent to commit suicide by handgun, would that prevent a physician (at least legally) from asking the patient if s/he had the means to carry through with the threat? Sigh. Democracy at work.

Olestra said...

1) Wouldn't this be a violation of freedom of speech? Wouldn't this violate the physician oath?

2) The unfortunate main idea here is that an important NEED is not being met. (The need being "gun safety education, specifically around children") Because this need is not being met it is handed to the pediatricians who may not appropriately trained and qualified in gun education but who ARE qualified and trained for many other issues that are not being addressed because they have to spend time discussing gun safety.

Perhaps the government should pass laws requiring gun safety courses for everyone who owns a gun, and perhaps the gun industry should be responsible to pay for these courses..??

jesse said...

What if the pediatrician has all parents sign a statement as a precondition to rendering treatment that gives the physician permission to ask any question, including related to the possession of firearms, that he deems necessary...

Wait! The right to be free of questions as to the possession of firearms shall not be abridged...

What about "I am not allowed to ask about firearms in the home, but if you would ask me.... No....

NneomaMD said...

the argument against asking about firearms is one of privacy - that pediatricians invade the privacy of their patients when they ask about firearms.

hmmm, i thought thought the doctor-patient relationship was ALL about invasion of privacy. don't know about the rest of you all, my pediatrician was a major violator of my privacy - you know, asking if my parents smoke, whether I'm having sex, sticking wooden popsicle sticks in my throat, swabbing stuff...and erggh...having the audacity to check my genitals once a year.

pediatricians, those lollipop-peddling, rascally privacy intruders...shakes my fist...

moviedoc said...

I oppose any further criminalization of the practice of medicine, but shouldn't physicians stick to diagnosing and treating illness? It seems we sorely challenged to get that right, much less all the ancillary activities we are expected to perform, like education, filling out forms, getting insurance money for people, deciding whether they can drive, when they should go back to work, etc, ad infinitum. Enough already.

Rob Lindeman said...

The statute would be unenforceable in practice.

In any case, where is the evidence that anticipatory guidance regarding gun safety has any benefit?

BTW, Nneoma is right. My job consists in large part of invading childrens' (and parents') privacy

Rob Lindeman said...

"Current evidence is insufficient to determine whether clinical advice influences patients to remove or safely store guns"

DiGuiseppi, C. Preventing youth violence. In: U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 2nd ed, DiGuiseppi, C, Atkins, D, Woolf, SH (Eds), Williams & Wilkins, Baltimore, 1996. p.687.

DiGuiseppi, C. Counseling to prevent household and recreational injuries. In: U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 2nd ed, DiGuiseppi, C, Atkins, D, Woolf, SH (Eds), Williams & Wilkins, Baltimore, 1996. p.659.

Anonymous said...

In the age of EHRs, a pediatrician -- or any doctor -- noting that there are guns in the home, is helping to compile a back-door gun registry for the Federal government. That is what the Florida law is trying to prevent -- introducing a First Amendment vs. Second Amendment scenario as it does so.

If gun safety is the issue, then address it with all families, as Meg said. That way it doesn't become part of someone's medical record.

Anonymous said...

and the physicians should give every parent a brochure about the dangers of bleach and other chemicals found in most homes. the should also ask if the family keeps matches for lighting birthday candles because so many kids die in fires every year. not only should they ask about gun ownership in the home but they must ask if anyone they know owns a gun. also butter knives since having too much butter on that slice of wonder bread will kill the kid.

Rob Lindeman said...

@anon directly above: Bravo! Well said!

Carrie said...

Let's see - for my program, we are required to do a plethora of H&Ps. For those, we must ask if there are guns in the home, lead paint, the temperature of the hot water heater, if the neighborhood is safe, diet, if the kid has friends in school, helmet use, seat belt use, SIDS prevention (if applicable), smoke detectors in every room, carbon monoxide detectors, child proofing the house, and so on - it gets overwhelming to me at times because I feel the bases we may need to cover could be endless. That being said, I do not in any way think that providers working with families should be penalized for asking about guns in the home. But then, I lost a teenage family member to an accidental gun death when I was quite young. I may be biased... Also, have seen patients who accidentally shot themselves and lived to tell the tale. Gun safety education wouldn't hurt... People think guns are the optimal self-defense, but guns lead to more accidents and injuries than any self-defense benefit.

Anonymous said...

I think any law circumscribing the discussion between a physician and patient is a ridiculous limitation on the exercise of the physician's professional judgment and discretion. If a physician asks a question that the patient thinks is inappropriate, the patient can decline to answer. If the physician persists in asking the question in a manner that the patient finds offensive, the patient can find another physician. It is absurd to legislate the content of physician/patient communications.

At the same time, I wonder what a physician would do with the information about guns in the home, if a patient provided it. Aside from a psychiatric setting, where information about guns might be immediately relevant, what would the physician do if the patient answered "yes, I keep a loaded gun in my night stand next to the baby's extra pacifiers." Is the physician in any position to provide meaningful education to the patient about her gun in the nightstand? Of what would the education consist?

A question about guns seems like one of those checklist things that seems like a good idea but is pretty much meaningless in terms of real preventive care. When I ended up in an urgent care, after being hit on my bicycle by an SUV, one of the questions the triage nurse asked me was "do you feel safe in your home?" To which I replied "yes, so long as I remember to feed the cat." I assume the question is supposed to have something to do with the prevention of domestic violence. But I wonder if anybody ever says "no" and, if they do, what course of action, if any, is taken.

jesse said...

Sometimes to arrive at core principles when examining an issue it helps to reframe it in another form. How would Florida's legislature react if there developed a movement among physicians to inquire as to whether there were a bible in the home?

Dinah said...

So, you know, it's not the gun ownership or safety issue that has me riled here...I don't really need peer-reviewed research proving that every word out of a doctor's mouth has been proven helpful. What has me riled is the concept of making it a crime for a doctor to ask a question. This law makes asking a question a Felony, punishable by a fine not to exceed $5 million dollars. I think I saw that that one rendition called for up to 5 years in jail (of course I can't find that).
Whether or not asking about safety issues is correlated with a change in behavior to create a safer patient, how do you find that it's reasonable to charge a physician with a felony and fine them $5 million (and likely take their license for the act of a felony), because a question-- well-meaning or otherwise-- was asked.

Anonymous said...

I think all drs should stick to treating disease or illness and leave the lecturing out of it. I never go to doctors except for broken bones and antibiotics and I do not answer questions about my lifestyle. Set the bone or figure how to stop green goo coming out of my head - nothing else is any of their business

jesse said...

Dinah, circle the wagons. But today's NY Times has an article about a ten year old shooting his neo-nazi father. This is no doctors business. Just take the green goop out of his nose.

Rob Lindeman said...

And Dinah, you can get as riled as you want: the statute is vague and unenforceable. It's political posturing, window dressing. It's just for show. Pick your analogy. I repeat - VAGUE AND UNENFORCEABLE

jesse said...

Rob, you may well be right. But do you know the huge personal and financial cost that can come to an individual who is charged with an eventually unenforceable law? And what the state board of medicine does with a physician convicted of a felony? This is chilling to the extreme.

Yes, it is likely unconstitutional,but think of what the physician who becomes the test case goes through.

Again, imagine if the physician were asking if the parents had a bible in the house. Would the legislature make asking that question a felony? Should a physician asking any question of a patient become a felony?

Anonymous said...

I just looked up and read the bill in question. It does not create a crime or impose any criminal penalties. Instead, it makes it a disciplinary matter for a physician or health care facility to ask questions about firearms, except under limited circumstances. The disciplinary sanctions that can be imposed include a fine of up to $10,000.00 per occurrence, as well as the usual array of suspension or revocation of licensure, limitations on practice, etc. I'm not saying that makes it a good idea, but at least it's not a felony, nor does it create the possibility of a $5 million fine. I don't think it's so vague as to be unenforceable or unconstitutional, but I'm sure those issues will be litigated in due time.

For the lawyers among us, or the curious-minded, you can find the bill on the Florida House of Representatives website. Just look up House Bill 155.

Dinah said...

Wow, I thought maybe I dreamed that, but I was sure I saw it....went back and it was the first version of the bill:

Yes, it they did drop some of that by version number 4.

(2)(a) A person who violates this section commits a felony
47 of the third degree, punishable, except as provided in paragraph
48 (b), as provided in s. 775.082, s. 775.083, or s. 775.084.
49 (b) A person who violates this section may be assessed a
50 fine of not more than $5 million if the court determines that
51 the person knew or reasonably should have known that the conduct
52 was unlawful.
53 (c) The state attorney with jurisdiction shall investigate
54 complaints of criminal violations of this section and, if there
55 is probable cause to indicate that a person may have committed a
56 violation, shall prosecute the violator and notify the Attorney
57 General.
58 (d) Notwithstanding s. 28.246(6), if a fine for a violation
59 of this section remains unpaid after 90 days, the Attorney
60 General shall bring a civil action to enforce the fine.

jesse said...

Thank you, Anonymous, for looking that up. At least it will not be a felony. But for a physician to defend his actions before the medical board is no mean thing. It's a big deal. You wrote:

"Instead, it makes it a disciplinary matter for a physician or health care facility to ask questions about firearms, except under limited circumstances."

Psychiatrists ask their patients all kinds of questions. There are a near infinite set of circumstances in which we might ask about firearms.

A patient would not say "hey, I'm suicidal or homicidal so I understand that it is appropriate to ask about firearms."

So in addition to the points about constitutionality and direct effect on the practitioner, consider the effect on medical malpractice. It might be malpractice to not ask about firearms, but the risk of one's license if one does ask.

Anonymous said...

In addition to the prohibition on asking about firearms the bill prohibits a physician from entering disclosed information concerning firearms ownership into a patient's medical record, except under limited circumstances. It also prohibits a physician from discriminating against a patient based on firearm ownership, requires a physician to "respect a patient's right to own or possess a firearm" and prohibits a physician from "unnecessarily harassing a patient about firearm ownership during an examination."

The question about medical malpractice is an interesting one. It's not my area of law, but my guess is that compliance with the statute would provide some defense to a med mal claim.

Anonymous said...

Tragic accidents happen with guns. They also happen with cars, slipping in the tub and riding a bike etc. Why would a lecture by some doctor stop or change behavior by someone who had guns? I do not understand why anyone would care what a doctor said about guns or anything else other than health care advice? And even then, it is just advice, it can be ignored. When did doctors become lifestyle police? Why do they want to be? Why do people want doctors to tell them what to do? That extra three years in school does not make doctors into gods.

Anonymous said...

I checked with mom, apparently our pediatrician was able to successfully treat me and my two siblings with nary a mention about guns or changing the batteries in our smoke alarms or leaving standing water to drown in or crossing the street unattended and so on. I guess he was too busy treating my sister's congenital heart defect to worry about educating responsible parents about things they were already doing.
My parents were and continue to be responsible gun owners, and no education was needed about gun safety from our pediatrician.

Parents who are irresponsible with guns are going to be irresponsible in a lot of other areas too. So, you might as well book appointments for them daily for months so you educate them about every possible risk under the sun.

Luckily most of the physicians we've dealt with recognize we have commmon sense and treat us that way.

Anonymous said...

As an Australian and a psychiatrist, I find this legislation unfathomable. In Australia, failure by a doctor to consider material risks to patient safety would be grounds for negligence were the patient to come to harm. And having access to guns at home would be considered a material risk.