How physicians can talk to patients about gun violence and firearm safety with Sandra Fryhofer, MD

. 17 MIN READ

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, Sandra Fryhofer, MD, who serves as AMA’s Board Chair and the inaugural chair of our Gun Violence Task Force, joins to discuss what physicians need to know about gun violence prevention. AMA Chief Experience Officer Todd Unger hosts.

Access AMA's CME module to help prepare physicians to counsel their patients on firearm safety on the AMA Ed Hub.

Additional 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. Also view this guide.
  • 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).
  • Read the American Journal of Public Health article, "Talking About “Firearm Injury” and “Gun Violence”: Words Matter."

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.

Speaker

  • Sandra Fryhofer, MD, chair, AMA Board of Trustees

AMA Recovery Plan for America’s Physicians

After fighting for physicians during the pandemic, the AMA is taking on the next extraordinary challenge: Renewing the nation’s commitment to physicians.

Unger: Hello and welcome to the AMA Update video and podcast. Today, we're discussing gun violence prevention. And I'm joined by the AMA's Board Chair, Dr. Sandra Fryhofer, who's also chairing the first phase of our gun violence task force. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Fryhofer, welcome back.

Dr. Fryhofer: Well, Todd, thanks so much for having me back. And we usually talk about vaccines and COVID types of things. But this time, we're talking about AMA's role in stopping this epidemic of gun violence facing our country.

Unger: Well, let's dig right in. You're chairing our new AMA Gun Violence Task Force. Why don't we just start by talking about how this task force came about?

Dr. Fryhofer: At our November 2022 meeting, our House of Delegates asked for this task force, specifically focusing on gun violence prevention, including gun—involved suicide. And I'm honored to be its chair for this first phase. By convening this task force, the House wanted to demonstrate AMA's commitment and leadership to the public and among other organizations. This is a serious and urgent issue.

So far, just since the start of 2023, the Gun Violence Archive reports more than 90 mass shooting events already this year. Hundreds of the dead and injured are children. The scope of this crisis goes beyond mass shootings, with suicides, homicides and unintentional shooting deaths happening every single day. Already in 2023, there have been more than 7,000 gun violence deaths across the nation. Over half of these were suicides.

Unger: So, obviously, a very, very urgent issue. This is going to be a AMA's first formal task force on gun violence. But the AMA is not new to this issue at all. Can you talk a little bit about some historical perspective?

Dr. Fryhofer: Well, you're right. Having a dedicated gun violence task force is new. But AMA has been calling for efforts to stop firearm violence since the 1980s. In fact, in 1998, AMA even published a physician's firearm safety guide, which was a primer for physicians with a broad overview of both public health and clinical issues.

In 2016, following that horrific shooting at the Pulse nightclub in Orlando, AMA declared gun violence a public health crisis. But, sadly, firearm injuries and deaths have continued to increase since that declaration. And it's not from a lack of AMA policy. AMA's passed more than two dozen policies supporting measures like extending waiting periods, strengthening background checks, and adopting extreme risk protection orders.

At our 2022 Annual Meeting, AMA adopted new policies to reduce firearm violence, including ensuring active shooter drills considered the mental health of children and advocating for warning labels on ammunition packages. Many of AMA's own advocacy efforts on gun violence prevention have widespread support from the American public, including banning assault weapons, high-capacity magazines and other weapons of war as well as expanding background checks and waiting periods for all firearm sales.

We've called for eliminating ghost gun loopholes. We've called for federal requirements for firearms storage. We've called for Congress to earmark funds for gun violence research and violence prevention efforts.

We were all encouraged last year when Republicans and Democrats in Congress came together. And after decades of inaction, Congress passed the Bipartisan Safer Communities Act, which was signed by the president. Now, this 2022 law isn't a panacea. But it's certainly a step in the right direction.

Unger: And speaking of the president, you represented the AMA at a White House event when that bill was signed by the president. Tell us more about that.

Dr. Fryhofer: Well, that was very exciting. This law reauthorizes funds and supports various programs, grants and activities to promote access to behavioral and mental health services, enhance school safety and security initiatives and address gun violence in communities. AMA has also been working with other federation organizations to ensure Congress appropriates increased funding to the CDC and NIH for research to prevent firearm violence.

AMA also continues to work with medical societies at the state level to encourage and assist states in implementing some of the new law's provisions, especially regarding passage of ERPO, which is Extreme Risk Protection Order legislation.

Unger: Well, speaking of that and the broader Federation of Medicine, there are lots of groups within medicine that are already working in this area. How does that affect the role that the AMA plays in the space? And what's the plan? And what's been done so far?

Dr. Fryhofer: You're so right. There are lots of different groups working on this. And we don't want to reinvent the wheel. So our first step was convening a very small number of specialties already deeply involved in gun violence issues to share resources and experiences and develop synergies among these groups to push for change.

We also wanted to reach consensus on the role for organized medicine in these efforts. So, I mean, where can the House of Medicine really make a difference? How can we make maximum impact?

We met with physician leaders and high-level staff from AAP, AAFP, ACP, ACS and APA. At this initial meeting held at AMA's Washington office, we also got feedback from several outside organizations, including Giffords, Brady End Famliy Fire and the Johns Hopkins School of Public Health Center for Gun Violence Solutions.

Unger: Dr. Fryhofer, can you share some insights from that DC task force meeting? What did you identify in terms of policy gaps?

Dr. Fryhofer: Well, there was consensus that the House of Medicine needs a unified, coordinated message for this public health crisis. There was consensus that we have plenty of policies. There was also consensus for sharing resources.

Unger: You met with the AAP, the American Academy of Pediatrics, AAFP, the American Academy of Family Physicians and ACP, the American College of Physicians. What did these primary care groups have to say?

Dr. Fryhofer: Dr. Lois Lee, who chairs AAP's Council on Injury, Violence, and Poison Prevention, shared some great resources on safe, secure storage of firearms to keep them out of the hands of children. Dr. Sterling Ransone, AAFP board chair, highlighted the lack of gun safety training. Dr. Sue Bornstein, chair of the ACP's Board of Regents, also participated.

The American College of Physicians has been very active in this space. And you might recall the response to ACP's 2018 study in the Annals of Internal Medicine actually started the social movement This Is Our Lane. ACP has many policy papers on gun violence. And a compendium of more than 50 studies on gun violence is available for free on their website.

Unger: And I recall that the discussion about This Is Our Lane. And I remember it having a lot—hearing from emergency physicians, for instance. But more broadly, you talk about surgeons, psychiatrists. What about those groups?

Dr. Fryhofer: Well, ACS, the American College of Surgeons, has recently updated their policies. Their focus is on the root causes of gun violence and making gun ownership as safe as possible. Gun violence has particularly taken a toll on historically marginalized and minoritized communities.

Dr. Eileen Bulger, medical director of ACS trauma programs, also talked about Project Inspire. A partnership with local juvenile gun crimes courts and the need for mentorship for at-risk youth. There is a complex relationship between mental health and community violence.

American Psychiatric Association President Dr. Rebecca Brendel called attention to dispelling myths about people with mental health. She reinforced people with mental health are not more likely to use firearms. But they are more likely to be victims.

Also, some people may be reluctant to get mental health treatment if they think it could affect their personal gun ownership. She also talked briefly about triggering events for removal of firearms and restoring access. Psychiatry representatives reinforced firearms are the most common tool for suicide. ACEP, the American College of Emergency Physicians, was represented by Dr. Megan Ranney, who voiced additional concerns about violence in the workplace and the need for more and better data.

Unger: And, obviously, we've got the groups that are inside medicine. And to make a real difference, also, I guess, teaming up with those that are outside. Talk to us a little bit about outside organizations. And how did they contribute?

Dr. Fryhofer: Well, the outside organizations that we had at this small meeting stressed the importance of community partnerships. Attorney Josh Horwitz, from the Johns Hopkins Center for Gun Violence Solutions, talked about possible reasons why gun violence is on the rise. He cited social unrest, social dislocation brought on by the pandemic, an increase in gun sales, an upsurge in permitless carry laws, as well as increases in alcohol consumption.

Another recurrent theme of the day was words matter. The language you use can either open up discussions or close them down.

Unger: That seems to be the case in so many topics these days. So I want to talk a little bit more about the importance of language and, as you said, using the right words so that the discussion can be open and not closed. Talk to us a little bit more about what you mean there.

Dr. Fryhofer: Well, lack of basic knowledge about firearms can be a barrier to talking with some patients. Some physicians own firearms and are familiar with them. But even if you're not a gun owner, you need to know the lingo.

AMA has links to Guns 101, which is an online tool on the bulletpointsproject.org website. And this has details about types of guns, ammunition and the right words to use to describe them.

Firearm safety and care CME

Identify a physician’s role in promoting firearm safety, follow trends in fatal and non-fatal injuries and describe firearm violence and survival care with behavioral health insights.

Unger: Tell us a little bit more about that. Can you give us some specific examples of what that content looks like?

Dr. Fryhofer: Well, first off, the term "gun" is broad. It includes BB guns, airsoft guns, and paintball guns. A gun that uses an explosive charge, a.k.a. gunpowder, is technically a firearm. Serious firearm owners call guns firearms. But gun is the word generally used by the public to refer to firearms.

They're basically two types—handguns and long guns. The most common type of handgun is a semiautomatic pistol. Revolvers are also handguns. Long guns include rifles and shotguns.

Another word not to use—don't say bullet. If you say bullet to a firearm owner, you've immediately lost credibility. Firearms use ammunition, which are cartridges for handguns and rifles. And bullets are just one part of the cartridge. The magazine is the part of the firearm that holds the cartridges. Ammunitions for shotguns are called shells, which contain either pellets or a slug.

Unger: So, obviously, a lot to learn and not to know there in terms of that language. Does this resource—you call it Guns 101—explain the difference between semiautomatic and automatic weapons?

Dr. Fryhofer: Yes. Semiautomatic means after the trigger is pulled and the gun fires, a new round of ammunition automatically goes in the chamber and is ready to fire with the next trigger pull. Fully automatic means the weapon continuously fires until the trigger is released and for as long as ammunition is available. Fully automatic firearms are also known as machine guns, and ownership is tightly regulated at the federal and state level.

Unger: Well, in terms of another related topic, this term assault weapons, which we hear a lot, what type of guns does that include? And what about AR-15, AK-47s, these kind of terms that we hear connected to that?

Dr. Fryhofer: Well, there's no universal definition of an assault weapon. However, semiautomatic firearms with detachable magazines and military-style features, like collapsible stocks or pistol grips, are often referred to as assault weapons. The AR and the AR-15 does not stand for assault rifle. It stands for ArmaLite, the company that developed it.

The AK and AK-47 stands for Automatic Kalashnikov. And it's named for the Russian inventor who designed it in 1947. Some gun owners may perceive the term assault weapon as pejorative or inaccurate. So, instead, say a AR-15-style rifle, AK-style rifle or semiautomatic rifle.

Unger: Dr. Fryhofer, is there a specific reference available that gives this type of guidance to folks?

Dr. Fryhofer: Yes. A 2021 article in the American Journal of Public Health by Dr. Marian Betz and colleagues, including Dr. Megan Ranney, who was at our meeting, is all about how words matter when talking about firearm injury and gun violence. Language about safe, secure firearm storage also matters. So this article suggests, instead of saying, are your firearms locked up? They advise saying, do you prevent access to your firearms by unauthorized individuals?

How best to say what you mean to say also depends on context. So instead of saying all guns should be stored unloaded and separate from ammunition, think about who you're talking to and what the firearm is being used for. The article's recommended languages—responsibly stage firearms intended for defensive purposes. Responsibly store firearms used for hunting or recreation.

And instead of saying firearm safety counseling, their preferred language is firearm responsibility, prevention of unauthorized access, or secure firearm storage counseling. It's a whole new language for many of us. But it's important to get the message across and keep that conversation open because we've got to make change in this area.

Unger: Dr. Fryhofer, you also represented AMA at Northwell Gun Violence Prevention Forum. You're one of a hundred dedicated health care leaders invited to attend this event in person. Tell us a little bit more about who was there. And what were some of the key take-home messages?

Dr. Fryhofer: The meeting was hosted by Northwell Health CEO Michael Dowling and focused on mobilizing collective efforts within the health care industry. Featured speakers included the U.S. Surgeon General, the president of the National Academy of Medicine, Senator Chris Murphy, and Steve Dettelbach, who's director of the BATF, the Bureau of Alcohol, Tobacco, Firearms, and Explosives. New York State governor also made a cameo appearance. There were several panels as well as breakout networking sessions.

And as for take-home messages, gun violence is the number one cause of death in children. They showed a PSA, a Public Service Announcement, with this message, it doesn't kill to ask. This PSA equated asking about safe, secure gun storage to asking if a ferocious tiger in the home is being kept in its cage. This message is important for parents, grandparents, aunts, uncles and friends. And it really resonated with me.

Unger: I've noticed those billboards around town. And you're right. It does make you think. You also talked about the need for data and the lack of research. Is it true that in the past, gun violence research was actually prohibited?

Dr. Fryhofer: Well, you're talking about the 1997 Dickie Amendment. And this was actually discussed by the president of the National Academy of Medicine at that Northwell event. This amendment did not outright ban research. It just cut the funding for it.

So for more than 20 years, CDC essentially stopped its gun violence research funding. That changed in 2019 with an omnibus bill, which included dedicating $25 million each year for gun violence research. And that was to be divided between CDC and NIH.

This degree of funding is better than nothing, but it's not enough. Certainly, when you consider the magnitude of this public health crisis, we need data for firearm deaths as well as for nonfatal firearm injuries. We also need to encourage, correct, and complete ICD-10 coding.

We need data in order to know what works and what doesn't. There's an urgent need to better understand the root causes of firearm injuries and deaths so we can develop and implement evidence-based interventions. We need data to evaluate the effectiveness of gun prevention efforts already in place.

Historically, there have been many roadblocks to getting that data. And gaps in data make it harder for researchers to evaluate which prevention strategies work best.

Unger: Now, Dr. Fryhofer, I know you're in the early stages of this initiative. But what sort of educational support is either already available or in the works so far for physicians?

Dr. Fryhofer: Well, AMA has already created a CME module to help physicians learn how to identify and counsel patients at high risk of firearm injury and death. Case studies focus on patients at risk of suicide, victims of domestic violence and parents with firearms in the home. This module is available for free on AMA's Ed Hub.

AMA also has a resource with different kinds of safety locks available and how they work. We're also developing and will soon launch an online tool with state-specific laws on counseling restrictions, safe storage and child access protection laws, temporary transfer requirements and Extreme Risk Protection Orders, often referred to as ERPO. This state law site as well as an updated CME module should go live in April or May of this year.

Unger: Well, it's a lot of information, a lot of work that's in action right now. Dr. Fryhofer, do you have any final thoughts?

Dr. Fryhofer: This work is very important. The devastation of firearm violence in America touches every state and every community. But this is only our first step in this initiative.

AMA senior management and advocacy and in health and science are now working on next steps for this task force initiative. In our next steps, we hope to involve even more physician organizations in our task force work. Meanwhile, AMA continues to push lawmakers to adopt common sense steps broadly supported by the American public to prevent avoidable deaths and injuries caused by firearm violence. And we'll be reporting back to our House of Delegates with an update in June.

Unger: Dr. Fryhofer, thanks so much for being here today. And thank you to you and the task force that work for the work that's in process right now. And I'm sure a lot more to come.

We'll be back soon with another AMA Update. You can find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today, and 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.

FEATURED STORIES