Doctors occupy a privileged position in our society. They are among the most trusted professions and they have significant but not absolute legal protections for the advice and conversations that they have with their patients. These two factors make doctors an excellent delivery mechanism for public health advice because people will give their doctor a fair hearing instead of automatically disregarding a message delivered from a less trusted source.
When I was a kid, the major messages that my pediatrician delivered to my parents was to use seatbelts, delead the house and minimize the amount of time us kids spent around lit cigarettes. The goal of these questions were to reduce the probability of harm from easily avoidable vectors. Today, pediatricians and other PCPS will often inquire about gun ownership as guns are one of the leading causes of death for individuals under the age of 25.
Kevin Drum is uneasy about these questions:
That said, should physicians ask about gun ownership? I’m not so sure. Carroll says he only wants to discuss “health risks,” and that’s appropriate. Doctors have expertise in the area of human health: that is, the biology and physiology of the human body. But that’s not the same thing as the safety of the human body.
Maybe in an ideal world where there are public health/enviromental/behavioral safety and risk assessment advisors that are fully trusted by the vast majority of the population and who sees people on a routine basis, this is a relevant beef, but I think in this world Kevin is wrong, and we will see a trend towards medical providers asking more lifestyle choice questions in the future. Right now, doctors are motivated to ask about guns because they are a major cause of preventable injuries and death to a group of people who die due to preventable deaths in large numbers. If there was a safety culture where every bullet is a strict liability of the weapon owner, where every weapon is properly locked up in secure gun safes, where the amount of firepower that is publiclly available is sufficient for hunting and home defense instead of the start of an insurgency, gun questions would be a minor question seldom asked unless the parents of the kids are open carrying with the safety off and a closed chamber. We don’t live in that world.
This trend will continue becuase providers are begining to get paid for population health metrics instead of a fee for service system. Fee for service could see added gun violence as a positive for the income of doctors and hospitals because more trauma victims means more procedures which means more billing opportunities. Reducing preventable serious injuries and death were a social good but under the fee for service payment model, the public health incentives were at long term conflict with provider payments. Insurance companies always had that motivation in order to reduce claims payout, but savings produced by providers giving good public health advice had not been shared with the providers actually doing the work. If anything, providers were expected to be altruistic and not get paid or not get paid well for their time.
That conflict is changing.
Population health payment systems through strict capitation, Accountable Care Organizations, or global budgets for large groups means providers want to avoid extremely expensive emergency and trauma utilization, they want to avoid six months of rehabilitation for a kid who statistically should be perfectly healthy or merely worried about a fractured tibia due to a shitty slide tackle during soccer practice. The payment systems are moving towards population health management where the doctor needs to know how to perform acute interventions, but their payments and livelihoods are far more dependent on helping people avoid the really easy ways of landing in the hospital.