Shortly after the shootings in Newtown, Connecticut, two of us received letters from our county sheriff in North Carolina asking whether one of our patients had medical or physical conditions that would preclude issuance of a permit to carry a concealed weapon. Uncomfortable with our limited knowledge about such permits and our expected role, and fearing that our participation could affect our relationships with patients, we began exploring the ethical, legal, and policy considerations regarding physician involvement in this process

Barnhouse, K.K.

Goldstein, A.O.

Richman, B.D.

Tulsky, J.A.

Viera, A.J.

Carolina Digital Repository

n engl j med 368;24 nejm.org june 13, 2013PERSPECTIVE2251NIH Role in Nurturing Clinician-ScientistsNIH as officers in the U.S. Public Health Service Commissioned Corps to fulfill their Selective Service obligation) were trained and developed scientific maturity and independence before pursu-ing research careers.The best attraction to a clinical research career may be the prom-ise to a physician of committed funding to conduct the clinically oriented or basic research of his or her choice. Goldstein and Brown argue that the best science done by physician-scientists occurs in an atmosphere that is not orient-ed to clinical outcomes but seeks only to elucidate basic biologic processes.4 Jeffrey Flier, dean of the Faculty of Medicine at Harvard Medical School, notes that it’s the confluence of talented indi-viduals and “magical” research opportunities at the NIH that enables success.5 The major con-tributions that clinically trained scientists have made to our un-derstanding of human biology have come not from anything unique about their research skills, but rather from their perspective derived from clinical experience or training that enables them to define and pursue important prob-lems in human biology, especially in a highly supportive research environment.The NIH hopes to serve as a catalyst for a national effort to nurture clinician-scientists by pro-viding such varied opportunities in an incubator-like environment, by demonstrating the value of in-vesting in protected research time, and by inspiring partner-ships and complementary clini-cally oriented research programs at major institutions.Disclosure forms provided by the author are available with the full text of this article at NEJM.org.From the National Institutes of Health, Bethesda, MD.This article was published on May 15, 2013, at NEJM.org.1. Wyngaarden JB. The clinical investigator as an endangered species. N Engl J Med 1979;301:1254-9.2. Schafer AI, ed. The vanishing physician-scientist? Ithaca, NY: Cornell University Press, 2009.3. Ley TJ, Rosenberg LE. The physician- scientist career pipeline in 2005: build it, and they will come. JAMA 2005;294:1343-51.4. Goldstein JL, Brown MS. A golden era of Nobel laureates. Science 2012;338:1033-4.5. Flier JS. Creating a Nobel culture. Science 2013;339:140-1.DOI: 10.1056/NEJMp1302969Copyright © 2013 Massachusetts Medical Society.Assessing Competency for Concealed-Weapons Permits — The Physician’s RoleAdam O. Goldstein, M.D., M.P.H., Kathleen K. Barnhouse, M.D., Anthony J. Viera, M.D., M.P.H., James A. Tulsky, M.D., and Barak D. Richman, J.D., Ph.D.Shortly after the shootings in Newtown, Connecticut, two of us received letters from our county sheriff in North Carolina asking whether one of our patients had medical or physical condi-tions that would preclude issu-ance of a permit to carry a con-cealed weapon. Uncomfortable with our limited knowledge about such permits and our expected role, and fearing that our participa-tion could affect our relationships with patients, we began explor-ing the ethical, legal, and policy considerations regarding physi-cian involvement in this process.Although the U.S. Supreme Court recently held that the Sec-ond Amendment protects an in-dividual’s right to possess guns for traditionally lawful purposes, that right is subject to reason-able legislative limitations. Fed-eral law, for example, prohibits gun sales to felons, persons found to abuse controlled sub-stances, persons with a history of domestic violence, and persons deemed dangerously mentally ill. The Brady Law requires back-ground checks for gun purchases from federally licensed dealers.Although denying weapons to people with prior convictions seems relatively straightforward, it’s more difficult to assess men-tal competence and current or future risk for violence. Even with drug testing, it’s often difficult to detect clinically whether a per-son is abusing illegal substances, controlled prescription drugs, or alcohol. Waiting periods for gun purchases vary by state, and sales by private parties require no back-ground checks or substance-abuse clearance.Every U.S. state allows some persons to carry certain concealed weapons in public, after varied approval processes. States also vary on who, if anyone, has the authority to deny gun permits to individuals — some states pro-hibit denial if certain criteria are met; others allow law-enforcement agencies to deny permits regard-less. The number of permit ap-plications for concealed weap-PERSPECTIVEn engl j med 368;24 nejm.org june 13, 20132252ons has surged — in Florida, for instance, from 28,618 in 2000 to more than 150,000 in 2011, and in Michigan from 29,914 in 2003 to more than 90,000 in 2010.1,2 Many states require local law-enforcement agencies to sign off on concealed-weapons permits, and applicants must disclose mental or physical conditions that could interfere with safe weapon handling. Local law-enforcement officers may require applicants to provide the name of a physi-cian who can attest to any aspect of their physical or mental health history that might make it inad-visable to allow them to have a concealed weapon.For those physicians, several concerns arise. First, assessment of competency requires training and standards, but no physician training programs or standards exist. Even professional recom-mendations that physicians as-sess whether patients are at in-creased risk for committing gun violence are rarely followed.3 Moreover, there’s no evidence that physicians can accurately assess patients’ ability to use weapons competently and safely.Although physicians can com-plete checklists about physical or mental health diagnoses, it’s unclear whether they can reliably prognosticate about the safety of a patient’s decision to carry a concealed weapon, a critical is-sue for assessing competency. For instance, since 2005, more than 150 people who received permits to carry concealed weap-ons in Michigan have commit-ted suicide.2 In North Carolina, over a 5-year period, more than 2400 permit holders were con-victed of crimes, including 900 drunk-driving offenses and more than 200 felonies.4 Given the number of patients with at least one condition that might affect their physical or mental function, it’s difficult to see how physi-cians can assess safety in the absence of comprehensive stan-dards. Instead, physicians may choose whether to sign off on such permits guided as much by their own views about gun own-ership as by any standard.An analogous situation arises from the requirement for medi-cal clearance for issuance of com-mercial motor vehicle licenses. The Department of Transporta-tion, however, has issued de-tailed regulations about who is considered a licensed medical examiner for “transportation” physicals, the duration for which clearance is granted, and condi-tions that might affect safety, including musculoskeletal, car-diac, respiratory, neurologic, en-docrine, emotional, and psychi-atric conditions. Applicants for commercial driver’s licenses must schedule a physician’s appoint-ment, which is treated as an of-fice visit and billed appropriately. The physician may recommend repeat assessments — for in-stance, for patients with severe hypertension or arthritis. In con-trast, the forms that physicians are asked to fill out for concealed-weapons permit applications lack details on what to assess or dis-close and vary substantially among jurisdictions.Second, there may well be substantial variation in what is considered to constitute mental and physical competence to car-ry a concealed weapon. Reason-able physicians might disagree about whether patients with Par-kinson’s disease, prior strokes, atrial fibrillation, seizures, or chronic pain are physically com-petent to use a weapon safely, as well as about whether people who have a history of depression, sub-stance or alcohol abuse, anxiety, or insomnia or who are taking psychotropic medications are mentally competent to do so. Guidance is needed regarding the need and protocols for col-lection of urine toxicology or blood alcohol reports to rule out drug or alcohol use before sign-ing off on permits.Third, requests to sign off on concealed-weapons permits may raise ethical questions for physi-cians. For instance, should phy-sicians disclose personal informa-tion about the patient’s childhood, such as a history of sexual abuse? Many physicians may see any par-ticipation in concealed-weapons approval as unethical, since it doesn’t serve a primary goal of medicine and may violate their religious beliefs. (Such conscien-tious objection resembles that of physicians with religious objec-tions to providing contraception to single women.) If physicians don’t wish to participate in these assessments, they can inform law-enforcement agencies, although they may fear that not signing a permit would damage their physi-cian–patient relationship.Fourth, several legal issues need clarification. When physi-cians convey private health in-formation to the state, they’re potentially vulnerable to liability claims under the Health Insur-ance Portability and Accountabil-ity Act. Clinicians have been sued for releasing records about pa-tients’ mental health even in re-sponse to subpoenas.5 There is also a threat of tort liability. Although many states provide immunity to liability for law-enforcement officials who make Assessing Competency for Concealed-Weapons Permitsn engl j med 368;24 nejm.org june 13, 2013PERSPECTIVE2253determinations about concealed-weapons permits, participating physicians may not have immu-nity. Some people who have been granted such permits have killed and injured others,4 and in most cases, their applications should have been denied. When physi-cians sign off on permits, do they share liability for these deaths? If a patient obtains a permit but is subsequently found to have a psychological or physical condi-tion that precludes safe or com-petent weapon use, must the phy-sician contact law enforcement — just as physicians in some states must report to the depart-ment of motor vehicles medical conditions that may preclude an ability to drive safely? Clarifying the physician’s role might help alleviate concerns about liabili-ty. For example, if police con-tracted with physicians for as-sessments, physicians would be agents of the state and more likely to be protected from lia-bility. Finally, perhaps new legis-lation might expand gun-free zones to include all health care settings.Moving forward, we believe policymakers and physicians’ or-ganizations should consider sev-eral issues. Federal legislation or rule making could help define national standards and guide-lines on what constitutes mental and physical competence to car-ry a concealed weapon and who can make those assessments. Ad-ditional research can help estab-lish standards, along with pro-tocols to assess and test for substance abuse, with input from physicians and public health and legal experts. Using these stan-dards, physicians could review pa-tients’ health histories, conduct physical examinations and labo-ratory testing, and recommend appropriate intervals for reassess-ments. If a patient’s physician declined to participate, the pa-tient could be referred to a physi-cian contracted by the law-enforce-ment agency who was trained in making such assessments.We also believe that medical education should incorporate broader violence-prevention train-ing that might resemble training for assessments of disability or competency for safe driving of commercial vehicles. Finally, pol-icymakers and professional orga-nizations should consider modify-ing legislation to prohibit carrying concealed weapons in clinical set-tings and should examine ways of limiting the liability of physi-cians who follow appropriate stan-dards, once such standards exist.Disclosure forms provided by the au-thors are available with the full text of this article at NEJM.org.From the Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill (A.O.G., K.K.B, A.J.V.); and the Department of Medicine, Duke University School of Medicine (J.A.T.), and Duke University School of Law (B.D.R.), Durham, NC.This article was published on April 17, 2013, at NEJM.org.1. Michigan State Police Criminal Justice In-formation Center. Concealed pistol licensure annual report: July 1, 2009 to June 30, 2010 (http://www.michigan.gov/documents/msp/ 2009-10_CPL_Annual_Report_343621_7 .pdf).2. Florida Department of Agricultural and Consumer Services, Division of Licensing. New Florida concealed weapon license ap-plications, fiscal year 1999-2000 through fis-cal year 2011-2012 (http://licgweb.doacs.state.fl.us/stats/CWApplications ReceivedByFiscalYearSince1999-2000.pdf).3. Price JH, Thompson A, Khubchandani J, Wiblishauser M, Dowling J, Teeple K. Per-ceived roles of emergency department phy-sicians regarding anticipatory guidance on firearm safety. J Emerg Med 2013 January 23 (Epub ahead of print).4. Webster DW, Vernick JS, Vittes K, Mc-Ginty EE, Teret SP, Frattaroli S. The case for gun policy reforms in America. Baltimore: John Hopkins Bloomberg School of Public Health, October 2012 (http://www.jhsph.edu/ research/centers-and-institutes/johns-hopkins -center-for-gun-policy-and-research/ publications/WhitePaper102512_CGPR.pdf).5. Turk vs Oiler. Case No.:09-cv-381-KMO 2010 (http://www.gpo.gov/fdsys/pkg/ USCOURTS-ohnd-1_09-cv-00381).DOI: 10.1056/NEJMp1302795Copyright © 2013 Massachusetts Medical Society.Assessing Competency for Concealed-Weapons PermitsSome major U.S. public health problems are perpetuated and exac-erbated at least in part by lifestyle choices and individual behavior. Policy makers at all levels of government are struggling to find ways of intervening to promote wellness and reduce unhealthy behaviors without overstepping the limits of their authority or infringing on personal liberties. What can and should government do to reduce obesity and tobacco use? On May 17, 2013, experts Thomas Farley, Steven Gortmaker, and Cass Sunstein addressed these and other questions about health promotion and the state in a roundtable dis-cussion moderated by Meredith Rosenthal.Health Promotion and the StateA video will be available with the June 20, 2013, issue at NEJM.org

Assessing competency for concealed-weapons permits - The physician's role

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