As a primary care physician, I regularly ask patients questions that many people would consider rude, inappropriately nosy or just irrelevant in polite conversation.
Do you wear your seat belt? How much alcohol do you usually drink? Do you use recreational drugs? Have you ever injected yourself with anything? Do you have sexual relations, and if so, with men, women or both?
Questions like these have long been a standard part of medical interviewing, and for good reason. The answers may reveal clues about a person's symptoms or physical findings on exam. If a person says he or she drinks heavily or has used intravenous drugs, I may be more alert to signs of liver problems when doing the physical exam and more inclined to order certain blood tests. The answers also help me know if the patient is at greater risk for common, yet preventable, causes of death, like H.I.V., car accidents and heart disease, so that I can counsel him or her.
There's one customary question, though, that I'm no longer allowed to ask. In June, Gov. Rick Scott signed a law barring Florida doctors from routinely asking patients if they own a gun. The law also authorizes patients to report doctors for "unnecessarily harassing" them about gun ownership and makes it illegal to routinely document firearm ownership information in a patient's medical record. Other state legislatures have considered similar proposals, but Florida is the first to enact such a law.
The law provides an exemption if the question is "relevant to the patient's medical care or safety," though it doesn't specify what would qualify as relevant. Penalties for violating the law include disciplinary action by the Florida Board of Medicine, which could include citations, fines and "remedial education."
The measure was introduced in the state Legislature after a pediatrician in Central Florida dismissed a mother from his practice when she angrily refused to answer a routine question about whether she kept a gun in her house. The doctor, Chris Okonkwo, said at the time that he asked so he could offer appropriate safety advice, just as he customarily asks parents if they have a swimming pool and teenagers if they use their cellphones when they drive. He said that he dismissed the mother because he felt they could not establish a trusting doctor-patient relationship.
Advocates of gun rights argue that routine questions about firearms violate their privacy, make them vulnerable to discrimination by insurance companies and the government, and "offend common decency," as Marion Hammer, a former president of the National Rifle Association who lobbied for passage of the bill, put it in letters to N.R.A. members. Ms. Hammer said that gun-owning parents had complained to her for many years about pediatricians' inquiries, which she believes are ineffective at preventing gun injuries.
She contends that such inquiries are part of a political antigun agenda by the American Academy of Pediatrics.
"You don't go to a doctor to be interrogated or intimidated," she said. "There's a clear line between violating privacy rights and imparting safety information."
The A. A. P. takes the position that guns are a public health issue and that pediatricians have a duty to ask about ownership because firearm injuries affect a large number of their patients. According to the group, firearms account for a third of all deaths from injury among teenagers and more than one in five deaths from injury among people ages 1 to 19.
The academy recommends that parents not have a gun in the home. When guns are present, it suggests they be kept unloaded, in a secure, locked place, with the bullets stored separately.
"There's no political agenda — we're talking about the safety of children," said Dr. Lisa A. Cosgrove, president of the group's Florida chapter. "The best way to protect them is to teach the parents how to protect them."
Because the new law directly conflicts with accepted medical practices, some of my pediatrician colleagues have told me privately that they worry that not asking about firearms could put them at risk of a malpractice claim if the patient subsequently dies of or is injured by a gunshot. Psychiatrists routinely inquire about guns, too, and the law's requirements potentially place them in a legal predicament.
As a general internist in South Florida, I often see the effects of gun violence. Many of my patients have been injured or disabled by a gunshot, or had a family member shot and killed. Shortly after the new law went into effect, local television stations broadcast a story about a 4-year-old in Miami who was accidentally shot by his 17-year-old half brother, who was playing with a .22-caliber rifle.
The Florida chapters of the A. A. P., the American Academy of Family Physicians and the American College of Physicians have filed a suit contesting the law as a violation of the First Amendment right to free speech. (Disclosure: I am a member of the A. C. P., the major professional organization for internists, but am not involved with the litigation.) The suit, which calls the gun inquiry rule a "gag law," contends that prevention is a cornerstone of medical practice and that free discussions are key to the doctor-patient relationship and are protected by federal privacy rules.
At the moment, however, those of us working in a clinic or hospital will have to imagine we live in a place where gun injuries aren't a public health issue and forget some of the questions we learned to ask in medical school. In doctors' offices in Florida, prevention has its limits.
