AMA Update covers a range of health care topics affecting the lives of physicians, residents, medical students and patients. From private practice and health system leaders to scientists and public health officials, hear from the experts in medicine on COVID-19, medical education, advocacy issues, burnout, vaccines and more.
In today’s AMA Update, we cover firearm-related injury and suicide—and the role physicians can play in helping to prevent it with Emmy Betz, MD, MPH, professor of emergency medicine and director of the "Firearm Injury Prevention Initiative" at the University of Colorado School of Medicine. Dr. Betz is also involved in The Colorado Firearm Safety Coalition and is an emergency medicine physician at CU School of Medicine. AMA Chief Experience Officer Todd Unger hosts.
Free firearm resources available at:
- The BulletPoints Project provides clinical tools for doctors and medical educators to help prevent firearm injury. This tool equips clinicians with knowledge on firearms, their uses, benefits, risks, and safety to help reduce chances of firearm injury and death in their patients.
- Lock To Live provides tools that can help you talk to patients and families about temporarily reducing access to potentially dangerous things like firearms, medicines, sharp objects or other household items.
- Firearm Life Plan offers peace of mind to older adult firearm owners and families. This site provides resources and downloadable toolkits to preserve firearm legacy and maintain safety. Safe firearm storage is recommended by the National Shooting Sports Foundation (NSSF).
Dial 9-8-8 if you or anyone you know needs help. The National Suicide Prevention Lifeline is now: 988 Suicide and Crisis Lifeline. It provides 24/7, free and confidential support for people in distress, prevention and crisis resources for you or your loved ones, and best practices for professionals in the U.S.
- Emmy Betz, MD, MPH, professor of emergency medicine and director of the "Firearm Injury Prevention Initiative," University of Colorado School of Medicine
Unger: Hello and welcome to the AMA Update video and podcast. Today we're talking about firearm-related injury and suicide and the role that physicians can play in helping to prevent it. I'm joined by Dr. Emmy Betz, a professor of emergency medicine and director of the Firearm Injury Prevention Initiative at the University of Colorado School of Medicine in Denver. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Betz, thanks so much for being here today.
Dr. Betz: Well, thanks for the invitation.
Unger: When we talk about firearm violence, many people think, probably off the top of our head, about mass shootings, of which we've had a lot in the past year or so. But suicides make up a significant portion of firearm-related deaths in the U.S. Let's just start by having you talk a little bit to help us understand firearm-related suicides and the trends in the data.
Dr. Betz: Yeah. I think it is really important that we acknowledge the role suicide plays in the larger issue of gun violence in our country. So over recent years, it's been about 60% of firearm deaths have been due to suicide. That number decreased a little bit in 2021 because homicides increased. But still, suicides account for at least half of all firearm deaths in this country, followed by homicide. The mass shootings, obviously incredibly traumatic for all of us psychologically, but they account for only about 1% of firearm deaths in this country.
Unger: And research has shown that 9 out of 10 suicide attempts using firearms are lethal, which highlights the fact that the means of self-harm a person uses plays a key role in whether they live or die. Why is that so important for suicide prevention?
Dr. Betz: Yeah, I think it's important to acknowledge that for suicide prevention we need a comprehensive approach that involves identifying people at risk, getting them the treatment that works, and so forth, really the much bigger picture. But guns or lethal means are a key part of that because we know—really, it's for three facts.
So the first is that the time period from which a person decides to attempt suicide to actually take action can be in the space of minutes to hours. So it's really a pretty short period of high risk. The second, though, is, as you mentioned, we know that firearms are uniquely lethal compared to medications or other methods of suicide. So if someone attempts suicide with a gun, about 90% of the time they'll die.
And the third piece is that there's hope. So people get better. We know from research that only about 10% of people who survive a suicide attempt later die by suicide. So if we can get people through those high-risk periods, it's unlikely that they will die by suicide. And so that's why we really talk about reducing access to firearms in particular as a core strategy for suicide prevention.
Unger: In this particular topic, a lot of disagreement here. It seems like it's so hard to get collaboration around taking common sense steps to prevent the kind of harm we're talking about. You recognize the importance of working with gun shop owners and firearm trainers around suicide prevention and firearms safety and have formed a coalition in your own community. How did this come about? What are the results of it?
Dr. Betz: So we modeled our program in Colorado, the Colorado Firearm Safety Coalition, after one that was started originally in New Hampshire. I think it actually comes from a core belief that we have more in common than perhaps we do that separates us. I think there's a lot of political division in the space of gun violence prevention. But actually nobody wants people dying by suicide. Nobody wants to lose family members. Nobody wants to lose friends. And so it's been really exciting to actually see how these messages, particularly of suicide prevention, have been really positively received by the firearms community because they want to help protect the people they care about, as well.
It's hard to measure the impact, but we are trying to do that. But I will say, just in the last five years, there's been really an explosion of these kinds of programs, these kinds of messaging, and I think it's really helping change the conversation that we're having about these topics.
Unger: That's great news. And kudos to you and the folks in your community for taking that step. Many patients who come to the ED with thoughts of suicide don't necessarily receive information on reducing access to lethal means. So you've been developing resources to keep firearms out of the hands of those in crisis. Describe to us the resources and tell us what impact they've had on firearms—suicides in your own community.
Dr. Betz: Yeah. So I think—I am an ER doctor. We've seen that often it's hard for clinicians to have these conversations because they might not know where to start, they might be worried about offending people and so forth. So we wanted to build resources that make it easier for clinicians to have those conversations but also easier for patients and family, importantly, to take steps on their own. So ideally, these are temporary and voluntary changes in firearm access.
So a couple of things—our group developed—with NIH support, we developed a tool called Lock To Live that's available for free online. We don't make any money off of it. But it's a tool for clinicians and patients to kind of work through options for how to reduce access to firearms. And then more recently, we've been working on out of home firearm storage, so working on developing firearm storage maps, building networks with retailers and ranges who are willing to temporarily and voluntarily store people's firearms either for suicide prevention or for other reasons that someone just might want the guns out of the home. And I think it's really going to take a broad approach with lots of different options, giving away locking devices and so forth, to get—to find the solutions that will work for different people.
Unger: I mean, you mentioned that that could be an awkward conversation. You have somebody come to ED with thoughts of suicide. Are they open to talking about making sure they don't have access to firearms at that point or their families? It seems common sense, but it probably must be, as you said, very tough in the moment to have that.
Dr. Betz: I mean, I think it's actually easier than we expect. I think particularly clinicians, we are trained to talk about the hard things, to talk about sexual practices and substance use and all kinds of things that might make us a little nervous at first. So some of this, I think, is that as clinicians we just need to get used to having the conversations. We know from research that patients are OK with us talking about this when it's in the context of something like suicide.
There are no federal laws or state laws banning physicians from doing this. And so I think it's really about making it patient-centered, making it routine but also individualized, the things we do for everything else really. And I think, if you do that and you come at it from a space of listening and wanting to support the patient, it's unlikely that you'll get a lot of pushback.
Unger: Now, another scenario that maybe wouldn't be top of mind has to do with your research that focuses on people with dementia and access to firearms—so obviously another sensitive topic for caregivers. What advice do you have on how to have that conversation to make sure that folks are safe?
Dr. Betz: Yeah. So the first thing I would say is we—from the work we've done and what we've learned from caregivers and older adult firearm owners is we're really trying to encourage people to have these conversations sooner than later. So ideally, older adults who own firearms themselves would make their own decisions ahead of time about what they want to happen if they develop dementia or other impairments or upon their death.
With NIH support, we developed a site called the Firearm Life Plan, which is a website. It's, again, free. We don't make money off of it. Happy to have people use it with some tips and tricks for how to think ahead about these issues.
For caregivers—once you get to the point where the older adult firearm owner perhaps is impaired and can't make that decision themselves, for caregivers, I think it's important to recognize a couple of things. So first, it's the disease, not the person, that's the problem. And emotionally, I think it can be hard, but it's important for people to come to terms that dad or mom is not who they used to be.
And then second, really, as in suicide prevention, it's about reducing access. There are lots of ways to do that. And we encourage caregivers to find the thing that works for them and their family, whether that's locking firearms up, moving them out of the home, selling them or so forth, depending on what the family wants. But it's really about making sure that impaired person doesn't have access.
Unger: Dr. Betz, you've also done work on suicide prevention in the veteran community. What are some of the key takeaways from this work that physicians should know about?
Dr. Betz: I would say two things. First, a huge kudos to the VA for really leaning into this space they. Are doing comprehensive, large-scale programs in education, outreach, PSAs to really talk about firearm and suicide prevention in particular. And I think it really are leading in this space. It's really exciting to see what they're doing.
For clinicians, I think one of the key takehomes is to think about, in veteran populations, firearm ownership rates are higher. Suicide rates are higher. There are also higher rates of things like PTSD, which may affect willingness to lock up firearms, for example, if someone is hypervigilant or concerned about safety. And people's relationship with guns might be different than in civilians. And I think those are things that come into play when you're talking about how to reduce access during times of suicide risk. But we know from studies in veterans, they are also OK with clinicians bringing these topics up and having these conversations.
Unger: Well, Dr. Betz, last question—what advice do you have for fellow physicians who are interested in doing more in their practice to address what is clearly a major public health issue?
Dr. Betz: Yeah, to jump in. I think, again, people are open to these conversations. I think, if you come at it from a standpoint of truly caring about harm reduction, injury prevention, it's not about politics. I encourage people to check out their resources that the AMA has developed, also resources from a program called Bullet Points in the state of California that have a lot of specific videos for clinicians about how and when to have these conversations. Learn more, figure out what works for your practice and then start doing it.
Unger: Dr. Betz. Thank you so much for being here today and for all the work that you're doing to raise awareness about and prevent firearm-related injury and suicide. That's it for today's episode. We'll be back soon with another AMA Update. In the meantime, you can find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.