To assess a patient’s overall well-being and potential health risks, clinicians routinely ask questions on a wide range of topics, such as car seats, mental health, diet, sexual activity, alcohol, exercise and smoking.

Physicians and researchers at the University of California, Davis, want providers to consider a new item for their list: firearms.

In a new paper published in the New England Journal of Medicine Evidence, the authors make a case for why discussions about firearms are appropriate in the exam room for patients who may be at risk of harm.

Their suggestion is supported by statistics.

In 2022, there were 48,204 firearm deaths in the United States.

More than half of those — 56% — were suicides, and 41% were homicides. Additionally, every year, an estimated 85,000 people sustain firearm injuries, which can leave survivors with long-lasting harm.

“Clinicians routinely ask about safety concerns, but most feel unprepared to talk about firearms,” said Amy Barnhorst, first author of the study and a psychiatrist at UC Davis Health. “And it can be a difficult topic because it’s often politically charged.”

Barnhorst is a professor of psychiatry and the director of the BulletPoints Project, which is funded by the state of California. The initiative trains health providers to identify patients at risk of firearm injury and help them reduce that risk.

“Patients view their health care provider as a trusted source of information. That trust needs to be maintained. Our framework gives clinicians practical tools to identify risk and engage patients in harm-reduction strategies without judgment or politics,” Barnhorst said.

A growing need as gun ownership and beliefs change in the U.S.

Firearm ownership is increasing in the U.S. Almost one third (32%) of adults own firearms, and an additional 10% live in households with firearms.

Between January 2019 and April 2021, about 7.5 million people became new firearm owners, three times the expected number based on prior trends.

The belief that firearms make a home safer has also increased. In 2000, 35% of the general public thought having a firearm made a home safer, which rose to 63% in 2014.

The percentage of firearm owners who thought guns made the home safer rose from 75% in 2017 to 81% in 2023.

Researchers point out that although firearms in the home may offer a sense of protection, they also pose risks.

People with firearm access have more than triple the risk of suicide and double the risk of being a homicide victim than those without firearm access.

A large-scale study in California found that handgun owners had firearm suicide rates that were almost eight times higher for men and 35 times higher for women than nonowners.

These conversations can feel difficult. But with training and a risk-based approach, clinicians can guide patients and their families to better understand the risks of having firearms in the home.”—Amy Barnhorst, professor of psychiatry and director, BulletPoints Project

Firearms are rarely discussed with health care providers

Research has shown that clinicians and firearm owners are receptive to discussing firearm safety, but these conversations rarely occur. Only 7.5% of adults in homes with firearms have ever discussed firearm access with a health care provider, according to surveys.

“This is about shared goals — keeping patients and families safe,” said Angela M. Bayer, first co-author and director of engagement and impact at the UC Davis Centers for Violence Prevention. Bayer also manages the BulletPoints Project. “By framing conversations around risk and safety, clinicians can build trust and tailor interventions to help prevent tragedies,” she explained.

The 3As Framework for Firearm Injury Prevention Counseling is designed to help clinicians from various disciplines identify patients and clients at risk of firearm homicide, suicide or other injury. This includes physicians, physician assistants, nurse practitioners, nurses, psychologists, social workers and therapists.

The authors outline three steps — the 3As — clinicians can take to reduce harm from firearms.

1. Approach: Be informed, respectful and focused on harm reduction. The approach should be individual to the patient. Know why people own firearms and understand they may be a key part of a patient’s identity.
2. Assess: Identify risk factors for suicide or interpersonal violence, such as mental health conditions, alcohol misuse, dementia, relationship loss and job loss, as well as thoughts or threats of harming themselves or others. When there are children in the home, clinicians should routinely ask about firearms.
3. Act: Select interventions based on the type and level of risk, ranging from safe storage counseling to temporary firearm transfers, mental health holds or civil protective orders.

The authors emphasize that conversations should be collaborative and individualized, focusing on harm reduction rather than risk elimination. They encourage clinicians to:

• Educate themselves on firearm basics, safe storage options and local laws.
• Use neutral, non-stigmatizing language that highlights risk and safety, not right and wrong.
• Offer practical resources, including locking devices or referrals to local programs.
• Follow up regularly, as risk factors can change over time.

“These conversations can feel difficult. But with training and a risk‑based approach, clinicians can guide patients and their families to better understand the risks of having firearms in the home,” Barnhorst said. “They can also help them recognize when and how to reduce access. Taking these steps can potentially prevent injury or death.”

Clinicians can learn more and register for the free online, on-demand continuing education course, “Preventing Firearm Injury: What Clinicians Can Do.”

Additional authors include Amanda J. Aubel, Hilary Gonzales, Rocco Pallin, and Garen Wintemute from both the Violence Prevention Research Program and the Firearm Violence Research Center, University of California, Davis.

Resources:

• Read the study in NEJM Evidence
• Visit the BulletPoints Project website
• Learn how to keep kids safe in homes with guns
• Read a related study in BMC Emergency Medicine

BulletPoints Project In the News:

• Remembering Papa: Northern California’s elderly face hidden epidemic of gun suicides
• Rural Minnesota doctors find patients open to off-site gun storage as suicide prevention
• New resource guide equips clinicians to discuss firearm access with patients