Tennessee Legislation 2012

Forum section for the discussion of pending Tennessee legislation and proposed legislation.

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Re: Tennessee Legislation 2012

Postby fl0at » Mon Jan 23, 2012 2:18 pm

SomeGuy wrote:Your assertion that we ought not mind a database however is absurd. We have seen in the past that time and again any database can and will be used against us. Databases need a Miranda warning.

And right now, firearms are a leading cause, and thus a probable cause, of accidental death among kids.


float, that statement was simply wrong. Do not parrot the lies of our enemies.


A leading cause does not mean the leading cause. Again, it is probability.

Cars have a higher probability, but can you think of the confounder, or a few?

1. More people own cars than guns.
2. More people encounter other cars than other guns.

Saying that we should counsel on cars over guns is akin to saying we should counsel on lung cancer over breast cancer. We should do both, in both instances.

This is why the checklist usually asks about child safety seats and what direction they are facing, as you well know.

The pocket guide is agenda, which is why are discussing this, right? Removing the agenda from the interview and getting to more scientific driven data. That should be our goal, not the removal or suggestion of removal of firearms, but that counselling is necessary. It is just the type of counselling that we need to do better on, and frankly, since I don't see that changing, I support the legislation to remove the routine screening.

I guess was I lack in my explanation, or reasoning behind saying that it is odd that we would protest the assertion that there may be a database. It isn't that we shouldn't mind a database, we should. We should work on getting the FOIA database issue closed. It is more that we shouldn't act too paranoid about databasing, because we are already databased. If law enforcement (government) runs my drivers license number, they'll see I have a permit. I think they can put one and two together.

And, if we want to be paranoid, why not be truthfully paranoid? I can think of several easier ways in which the government can build, in secret, a database of gun owners that would be much easier than dealing with medical records, that may be incomplete, as you know. The easiest way? A simple man in the middle attack that logs every background check conducted when purchasing a firearm. Done. Clean, efficient, no hassle, relies on no other outside party, undetectable and already in use by various entities of the US Government.

So let's at least be reasonable in our fears, otherwise we look fearful. And honestly, scared people are easier to push around than loud and proud people. The goal, or at least idea, I thought, was that the government should be scared of the people. Well, right now, we look scared of the government.

I need no part of that.
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Re: Tennessee Legislation 2012

Postby fl0at » Mon Jan 23, 2012 2:57 pm

Your assertion that we ought not mind a database however is absurd. We have seen in the past that time and again any database can and will be used against us. Databases need a Miranda warning.

And right now, firearms are a leading cause, and thus a probable cause, of accidental death among kids.



float, that statement was simply wrong. Do not parrot the lies of our enemies.



A leading cause does not mean the leading cause. Again, it is probability.

Cars have a higher probability, but can you think of the confounder, or a few?

1. More people own cars than guns.
2. More people encounter other cars than other guns.

Saying that we should counsel on cars over guns is akin to saying we should counsel on lung cancer over breast cancer. We should do both, in both instances.

This is why the checklist usually asks about child safety seats and what direction they are facing, as you well know.

The pocket guide is agenda, which is why are discussing this, right? Removing the agenda from the interview and getting to more scientific driven data. That should be our goal, not the removal or suggestion of removal of firearms, but that counselling is necessary. It is just the type of counselling that we need to do better on, and frankly, since I don't see that changing, I support the legislation to remove the routine screening.

I guess was I lack in my explanation, or reasoning behind saying that it is odd that we would protest the assertion that there may be a database. It isn't that we shouldn't mind a database, we should. We should work on getting the FOIA database issue closed. It is more that we shouldn't act too paranoid about databasing, because we are already databased. If law enforcement (government) runs my drivers license number, they'll see I have a permit. I think they can put one and two together.

And, if we want to be paranoid, why not be truthfully paranoid? I can think of several easier ways in which the government can build, in secret, a database of gun owners that would be much easier than dealing with medical records, that may be incomplete, as you know. The easiest way? A simple man in the middle attack that logs every background check conducted when purchasing a firearm. Done. Clean, efficient, no hassle, relies on no other outside party, undetectable and already in use by various entities of the US Government.

So let's at least be reasonable in our fears, otherwise we look fearful. And honestly, scared people are easier to push around than loud and proud people. The goal, or at least idea, I thought, was that the government should be scared of the people. Well, right now, we look scared of the government.

I need no part of that.

Sorry for double post, computer is screwy.
Last edited by fl0at on Mon Jan 23, 2012 3:00 pm, edited 2 times in total.
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Re: Tennessee Legislation 2012

Postby fl0at » Mon Jan 23, 2012 2:57 pm

From your CDC link:

#3 Leading cause of death among 15-19: Suicide
#1 effector of suicide: Firearms

#2 Leading cause of death among 15-19: Homicide
#1 effector of homicide: Firearms

#1 Leading cause of death among 15-19: Unintential Injury
#1 effector of unintential injury: MVA
#5 Firearms

-------------------------------------
#4 in 10-14 yo: Homicide
#1 effector: Firearms

#3 in 10-14: Suicide
#2 effector: Firearms

#2 Neoplasm. Not much we can do there

#1 Unintentinal Injury
#1 effector: MVA
#9 effector: Firearms

------------------------------------

And let's consider this:

Of the 3270 deaths listed in the top 10 range for the age group from 1-4, 70 died from firearms.

Only 71, the #7 cause, died from septicemia. This means that firearms are the #8 leading cause of death among 1-4 year olds. Homicide by firearm is the #10 leading cause of death among 1-4 year olds.

Firearms are a leading cause of death among children. So are cars, so are bugs. We educate on both of those as well.

You know this better than anyone else here; medicine is about prevention. There isn't much we can do for SCLC after you get it... but we can at least attempt to limit the number of people who get it through education. There isn't much we can do about a lot of issues in medicine, after the fact. If you eat fatty food, high salt diet, lots of alcohol and don't exercise and are obese, there isn't much we can do about your soon to be DVTs progressing to PE, your BP control, Type II DM, vascular disease, CHF, nephropathy, liver failure, and etc. What we can do buys time... but the best friggen thing possible is to simply prevent it from occurring.

This is the purpose of firearms counselling. Prevention. Not complete removal. Ever been to a doc and he said you can never have Lay's chips again? Never have McDonalds again? Never have a drink? Must run a marathon a month? No. But, if you do all of those things... be smart about it. If you own firearms... be smart about it.
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Re: Tennessee Legislation 2012

Postby SomeGuy » Mon Jan 23, 2012 3:20 pm

This is the purpose of firearms counselling. Prevention


When they say prevention, they mean prevention of ownership. We are at least agreed upon the need to remove routine questioning from medicine, it serves no purpose but to diminish the profession.

As for suicide and homicide; suicide prevention should not equal gun ownership prevention. We had a very unhappy incident a few years ago when I was a brand new RN, where a man committed suicide with a blanket a few minutes after a Doc gave him some very bad news. Suicide prevention should focus on talking to people and seeing what is going on, not in lecturing them on fictional evils of firearms. To call firearms "a leading cause" is misleading, the gun didn't beg them to commit suicide, their own emotional issues did. The gun was a tool. Regarding homicide, consider the ages you picked. The CDC doesn't have this data, but I wonder what kind of gang activity is going on with early, and especially late teens? Again, pinning the firearm as the #1 effector is misleading, and again does the work of anti-gunners for them. On the younger children; it is still misleading to call them a leading cause, when the top 3 account for what, 70% of deaths and you grab #8, which is >1%? As you note, septicemia is in this catagory, perhaps we should install and maintain IV pumps and keep a penicillin drip in all homes. Absurd? Entirely, so too is advocating complete removal of firearms as a "cure".

The NRA man 1st Freedom had an interesting section regarding children and firearms, by chance did you see it?
J. E. F. II, MSN, RN.
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Re: Tennessee Legislation 2012

Postby Tim Nunan » Mon Jan 23, 2012 3:42 pm

fl0at wrote:The routine screening of firearms in homes during well child visits just needs to end, in its current form. The good news is that many of the forms are check in the box, not yes, no. For example, a form might say:

[ ] Counselled on Firearms safety.

vs

[ ] Are there firearms in the house?


The top one is the one I see on well child check-ups. It doesn't state that there are or are not firearms in the home, just that firearms safety is counselled. It is usually around the box for the Poison Control Hotline near the phone counselling and the water heater below 120 degrees, counselling. It doesn't state whether or not there are firearms in the home, just that counselling occurred. Keep it out of reach, put a lock on it, etc, or, as I prefer, that firearms safety instruction classes exist, and one should consider taking one.


Why should anyone presume that their doctor is qualified to "counsel on firearms safety"?
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GOA member

"A nation of sheep will beget a government of wolves." - Edward R. Murrow
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Re: Tennessee Legislation 2012

Postby fl0at » Mon Jan 23, 2012 3:58 pm

Tim Nunan wrote:Why should anyone presume that their doctor is qualified to "counsel on firearms safety"?


In the same way that you don't need to be a NASCAR driver to counsel on proper seat belt usage, a microbiologist to counsel on hand washing and germ spreading, or a demolitions expert to counsel on not holding that firework in your hand when it goes bang... you don't really need to be a firearms expert to advise someone that toddlers probably shouldn't be running around with a loaded weapon.
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Re: Tennessee Legislation 2012

Postby fl0at » Mon Jan 23, 2012 4:13 pm

SomeGuy wrote:
This is the purpose of firearms counselling. Prevention


When they say prevention, they mean prevention of ownership. We are at least agreed upon the need to remove routine questioning from medicine, it serves no purpose but to diminish the profession.

As for suicide and homicide; suicide prevention should not equal gun ownership prevention. We had a very unhappy incident a few years ago when I was a brand new RN, where a man committed suicide with a blanket a few minutes after a Doc gave him some very bad news. Suicide prevention should focus on talking to people and seeing what is going on, not in lecturing them on fictional evils of firearms. To call firearms "a leading cause" is misleading, the gun didn't beg them to commit suicide, their own emotional issues did. The gun was a tool. Regarding homicide, consider the ages you picked. The CDC doesn't have this data, but I wonder what kind of gang activity is going on with early, and especially late teens? Again, pinning the firearm as the #1 effector is misleading, and again does the work of anti-gunners for them. On the younger children; it is still misleading to call them a leading cause, when the top 3 account for what, 70% of deaths and you grab #8, which is >1%? As you note, septicemia is in this catagory, perhaps we should install and maintain IV pumps and keep a penicillin drip in all homes. Absurd? Entirely, so too is advocating complete removal of firearms as a "cure".

The NRA man 1st Freedom had an interesting section regarding children and firearms, by chance did you see it?


These are the top 10 causes, not all deaths. It is #8, out of the top 10. These are the leading causes of death. They are not all deaths, just the top 10. Think about what the title of the CDC database reflects "The Leading Causes of Death." By definition, of the description of the data, these are the leading causes. If you extract firearms deaths, and count them, in that category, it is #8... of the top 10 leading causes, which are by definition of the data... the leading causes.

If you want to go round about as you are, we can. It isn't McDonald's that caused your elevated cholesterol, it was the break down in the transport mechanism. McDonald's was just the tool. It wasn't smoking that caused your lung cancer, it was the malfunction of the repair system in your DNA that causes the mutation. Smoking was just the tool. It wasn't the sugar that caused your diabetes, it was a breakdown in the effectiveness of the insulin you produced. The sugar was just the tool!

Does the above sound ridiculous, as a medical practitioner, to you? Good, it should.

The absurdity, actually, is the erroneous comparison that continuously applying the intervention will solve the issue of septicaemia. As you know, that will make the issue worse. You'll destroy the normal flora in your body, and you'll likely cause resistant strains to emerge. However, if you said we completely eradicate the bug... then they'd be equal to completely removing firearms. But this is beyond the point.

The point is that we can lessen deaths from septicaemia by better understanding of the microbiology of the microorganisms, better pursuit of less infection by more screening, more prevention and more intervention applicable to the microorganism... not eradicating the bug completely. Thus, we can better lessen the death load from firearms by... screening, prevention and intervention... not eradicating firearms.

But, for sake of discussion... the #8 cause (firearms) is minor. Thus, along the same lines, the #7 cause (septicaemia) is also minor... so we should stop screening for firearms... and stop screening for bacterial infection? No. I don't think so. Medically, do you?
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Re: Tennessee Legislation 2012

Postby SomeGuy » Mon Jan 23, 2012 7:53 pm

you don't really need to be a firearms expert to advise someone that toddlers probably shouldn't be running around with a loaded weapon.


Given that I brought a direct quote from AAP materials into this thread earlier showing what they are actually pushing, you know that is disingenuous to say. The purpose of the "firearm safety" advice is not common sense, it is geared towards diminishing ownership, and relies on the respect that the medical and nursing professions have earned to push this agenda.

Being in the top 10 does not mean it ought to be "a leading cause". My point has been, and remains that to classify something "a leading cause" ought to mean it involves a significant number of deaths. The overly broad label dilutes the importance of actual issues that kill significantly more. Firearms as a cause of accidental death do not belong in the leading causes group, it diminishes the real causes, such as MVA, suffocation etc. By your standards, anti-gunners could always expand the leading causes list to keep firearms in it so as to always keep them demonized.

Returning to the anti-gun materials the AAP pushes, it spends more time concerned with firearms than causes that are much greater. It is openly misleading.

If you want to go round about as you are, we can. It isn't McDonald's that caused your elevated cholesterol, it was the break down in the transport mechanism. McDonald's was just the tool. It wasn't smoking that caused your lung cancer, it was the malfunction of the repair system in your DNA that causes the mutation. Smoking was just the tool. It wasn't the sugar that caused your diabetes, it was a breakdown in the effectiveness of the insulin you produced. The sugar was just the tool!

Does the above sound ridiculous, as a medical practitioner, to you? Good, it should.


Quite ridiculous, but for a different reason. You have no concious ability to control what your pancreas does regarding insulin production and blood sugar, same for cholesterol (though the McDonalds is a bad habit that will likely exacerbate the problem). Picking up a gun and committing suicide is a very concious decision, one that requires a person to think it is a good idea and act on it. Cigarettes are likewise a poor example you use. While it to requires concious thought, there are no benefits of cigarette smoking. To even consider them comparable in a conversation on firearms diminishes the value of firearms to our society both in daily protection from criminals, recreational uses, and defense of liberty.

Since you mentioned self-destructive activity (smoking) in your argument, let us consider firearm suicides a moment. A person is considering suicide, is screening for firearms the best way to treat this, or would it not be better to actually talk to the person about what they are thinking, and planning. IF they bring up firearms then so be it, but what medical purpose is advanced from inquiring about firearms if the patient is not thinking of using one to commit suicide? As a practitioner you treat the patient, you can look earlier in this thread for my example conversation in that vein. Are there firearm suicides? Yes. Should practitioners be aware of them, and prepared to inqure about them? Yes. Should practitioners bring it up first? Absolutely not. Suicide prevention is not the same as firearm prevention. A comparison of Japans suicide rate, and the methods used against the USAs shows this quite well.

The point is that we can lessen deaths from septicaemia by better understanding of the microbiology of the microorganisms, better pursuit of less infection by more screening, more prevention and more intervention applicable to the microorganism... not eradicating the bug completely. Thus, we can better lessen the death load from firearms by... screening, prevention and intervention... not eradicating firearms.


Screening, preventing, and intervening in ownership of firearms, as if it were an infection that might kill you whether you wish to die or not? Let us consider the comparison you make:
"The point is we can lessen the deaths where firearms are involved by better understanding the reasoning people own firearms, better pursuit of educating our patients to the danger of firearms, preventing ownership by encouraging laws to be passed restricting firearms, and intervening in their use by unregistered persons." How can you seriously consider firearms, an inert mechanical object that is less complex than a cell phone with a living pathogen that kills people? By the comparison you make firearms are as bad as sepsis; thankfully sepsis is not really comparable to firearm ownership (but it would be nice if the love of firearms and ownership/activity in protecting our rights was as easily transmitted as the common cold).

Continuing your poor comparison of firearms to sepsis, consider, a patient enters the office, complains of a fever, is lethargic and has not urinated in 2 days. This patient clearly requires aid. A person with a firearm on his hip, or a rifle in his truck however, does not need any questioning of his firearms simply because he entered a clinic.

But, for sake of discussion... the #8 cause (firearms) is minor. Thus, along the same lines, the #7 cause (septicaemia) is also minor... so we should stop screening for firearms... and stop screening for bacterial infection? No. I don't think so. Medically, do you?


The firearm is not a CAUSE. I cannot blame my keyboard when I mistype a word in a paper. Sepsis however IS a cause. There is no legitimate medical/nursing/healthcare reason to screen for firearm ownership as if it damages health like high blood pressure will. No amount of strawman arguments will change that.
J. E. F. II, MSN, RN.
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Re: Tennessee Legislation 2012

Postby fl0at » Mon Jan 23, 2012 9:36 pm

SomeGuy wrote:
you don't really need to be a firearms expert to advise someone that toddlers probably shouldn't be running around with a loaded weapon.


Given that I brought a direct quote from AAP materials into this thread earlier showing what they are actually pushing, you know that is disingenuous to say. The purpose of the "firearm safety" advice is not common sense, it is geared towards diminishing ownership, and relies on the respect that the medical and nursing professions have earned to push this agenda.


No. The purpose as far as the AAP is concerned. How many doctors do you think follow, rigidly, the guidelines of the AAP? How about the AMA? It isn't a universal viewpoint, which is why we should lean more on providers to adopt a common sense approach, not an all or nothing approach.

The issue I see is that if we start dictating to providers what they can and cannot ask in the interview, we will drive the sensible practitioners further away from a common sense approach, and move into the area we don't want -- straight recommendation on banning.

The further you get into that pocket book, you will undoubtedly realize that many of the guidances are not in practice, not used, and simply not appropriate in the office.

At the same time, I don't see these political groups, of which many of these societies are, especially the AMA, as backing off their stance, which is why I can support legislation to stop asking. But that doesn't mean it is the right approach. It is not for us to dictate to the provider what is medically relevant. And if the provider feels that it is medically relevant, we do a disservice to our patients by not asking.

I could care less what the AMA, ACP, AAP and the list goes on says is important in the office. That is their opinion and approach, not mine. But to lump all practitioners in the same category as these politically motivated groups is simply unfair. Very few practice strict adherence to these guidelines. By limiting their history taking, we are doing harm to them and possibly their patients. I'm not disagreeing with you about what the AAP is stating, I'm disagreeing with you on how we should approach the issue. And if we take the approach that all providers are operating along the guidelines of the AAP, I think we are making the wrong assumption, at least in this State, and it has the potential to push others who may be more receptive to altering the approach away.

SomeGuy wrote:
Being in the top 10 does not mean it ought to be "a leading cause". My point has been, and remains that to classify something "a leading cause" ought to mean it involves a significant number of deaths. The overly broad label dilutes the importance of actual issues that kill significantly more. Firearms as a cause of accidental death do not belong in the leading causes group, it diminishes the real causes, such as MVA, suffocation etc. By your standards, anti-gunners could always expand the leading causes list to keep firearms in it so as to always keep them demonized.

Returning to the anti-gun materials the AAP pushes, it spends more time concerned with firearms than causes that are much greater. It is openly misleading.


I understand what you are saying, that if we extract MVA from the injury list, and set it at #1, and extract suffocation, and set it at its individual level, we put firearms deep into the list. But firearms accidents still rank near things we still screen for. So saying that it is minor and we shouldn't screen, but believing that something further down the list that is also minor should be screened for, is doing exactly the same thing as our opponents, just on the other side of the spectrum. We should screen for all of them, especially when it doesn't take long and it might be beneficial. But this only comes from the common sense approach, which is the true goal, prevention. Like I said much earlier, several groups have lost sight of the original goal.

If you want to go round about as you are, we can. It isn't McDonald's that caused your elevated cholesterol, it was the break down in the transport mechanism. McDonald's was just the tool. It wasn't smoking that caused your lung cancer, it was the malfunction of the repair system in your DNA that causes the mutation. Smoking was just the tool. It wasn't the sugar that caused your diabetes, it was a breakdown in the effectiveness of the insulin you produced. The sugar was just the tool!

Does the above sound ridiculous, as a medical practitioner, to you? Good, it should.


Quite ridiculous, but for a different reason. You have no concious ability to control what your pancreas does regarding insulin production and blood sugar, same for cholesterol (though the McDonalds is a bad habit that will likely exacerbate the problem). Picking up a gun and committing suicide is a very concious decision, one that requires a person to think it is a good idea and act on it. Cigarettes are likewise a poor example you use. While it to requires concious thought, there are no benefits of cigarette smoking. To even consider them comparable in a conversation on firearms diminishes the value of firearms to our society both in daily protection from criminals, recreational uses, and defense of liberty.

Since you mentioned self-destructive activity (smoking) in your argument, let us consider firearm suicides a moment. A person is considering suicide, is screening for firearms the best way to treat this, or would it not be better to actually talk to the person about what they are thinking, and planning. IF they bring up firearms then so be it, but what medical purpose is advanced from inquiring about firearms if the patient is not thinking of using one to commit suicide? As a practitioner you treat the patient, you can look earlier in this thread for my example conversation in that vein. Are there firearm suicides? Yes. Should practitioners be aware of them, and prepared to inqure about them? Yes. Should practitioners bring it up first? Absolutely not. Suicide prevention is not the same as firearm prevention. A comparison of Japans suicide rate, and the methods used against the USAs shows this quite well.


You do have conscious control over portion sizes, exercise, what you eat, what you don't eat and everything that leads to a great number of maladies. You don't believe lack of exercise (often conscious), poor diet (often conscious) and not having self control over how much carbs you ingest doesn't play a major role in development of Type II DM? You don't believe that life choices and life style play a huge role in not only progression, onset and outcome of several rather common disease states? A person who chooses to use lots of salt on their meals, because they think it tastes good and thus thinks it a good idea, consciously decided to do something bad for themselves. They exhibited every single stage that the person committing suicide did, except maybe mental anguish. Instead they got pleasure and malignant hypertension, not death.

Now, there are a lot of issues with cholesterol that are not conscious, but are instead genetic. There are lots of issues with BP that are not conscious decisions. There are lots of disease states that cannot be prevented. Which is why so much emphasis is placed on those that can be prevented. I thought you handled your suicide example beautifully. You were direct in your question, when asking if they were going to hurt themselves, instead of beating around the bush. You didn't put a thought into their head and you handled it the exact way the crisis center would. And you are absolutely correct, suicide prevention is not firearms prevention. Just as nutritional counselling is not hypertension prevention. But there is still nutritional counselling. In suicide intervention, you are not looking to limit unintentional acts. In firearms counselling, you are trying to raise awareness of the unintentional action. Again, in the common sense approach. Therefore, it does have a role. It does not a role in eliminating death by suicide, death by homicide, or death by unintentional action, it merely serves as a tool in the overall picture.

Screening, preventing, and intervening in ownership of firearms, as if it were an infection that might kill you whether you wish to die or not? Let us consider the comparison you make:
"The point is we can lessen the deaths where firearms are involved by better understanding the reasoning people own firearms, better pursuit of educating our patients to the danger of firearms, preventing ownership by encouraging laws to be passed restricting firearms, and intervening in their use by unregistered persons." How can you seriously consider firearms, an inert mechanical object that is less complex than a cell phone with a living pathogen that kills people? By the comparison you make firearms are as bad as sepsis; thankfully sepsis is not really comparable to firearm ownership (but it would be nice if the love of firearms and ownership/activity in protecting our rights was as easily transmitted as the common cold).


I believe you missed the point. In your example, you suggested that it would be as ridiculous to continuously run antibiotics at all times as it would be to advocate removal of firearms as a cure. I am saying that the comparison is erroneous. If we didn't have to worry about opportunistic infection from the decreased normal flora, if we didn't have to worry about emerging resistance, and if we could kill the pathogen without harming the patient, and doing so in a cost effective way... we would run IV Ab 24/7. In other words, we would attempt to completely rid the planet of the pathogen. This is the only way that this example could equate to removal of firearms completely. However, we cannot, will not and do not, and thus your comparison is not valid. That is my point. Instead, we tend toward prevention. Again, my point. We do this by limiting the spread of the bug by hand washing, we do this by finding new approaches to kill the bug by using new drugs or combining other therapy. If we were to use the IV drip vs the handgun counselling as the def acto model, the only way to compare the two treatments is in prevention. My point. Thus, how we work to prevent septicaemia and how we work to prevent firearm related accidents work similarly, we observe, we counsel and we intervene. That was the point.

Continuing your poor comparison of firearms to sepsis, consider, a patient enters the office, complains of a fever, is lethargic and has not urinated in 2 days. This patient clearly requires aid. A person with a firearm on his hip, or a rifle in his truck however, does not need any questioning of his firearms simply because he entered a clinic.


Consider the patient who comes into your office with complaints of generalized joint pain, has a malar like rash on his face and hearing loss that lateralizes, though no obstruction is noted. Can you think of a scenario where knowing that this patient owns firearms will help exclude a very costly test (~$850) from your differential?

I can. It is a bit contrived, but follow for fun. Bob, 23, comes into the clinic with CC polyarthritis. During history, pt reports family history of rheumatoid arthritis on maternal side. Patient states joint pain is 1 month duration, and denies any other abnormalities. A red rash is noted sub-orbitally extending across the nose. Pt is advised that condition is not chronic, but due to family history and lupus like face rash, coupled with hearing loss, it is suggested that the patient have ANA and RF testing. Due to cost effective nature of doing these two tests in a panel, we order the panel. $850 billed.

ANA negative. RF negative. Insurance cost $850 test+$40 office visit, patient co-pay $350.

Now, if I said, "Do you own guns?" and he replied "Yea, I duck hunt, just got back this weekend." I would have asked, "Did you wear ear protection" "No, was in a blind and needed to communicate with friends." Hearing loss acute, removed from symptoms. "Did you wear any sunscreen?" "No, just these sunglasses." "So that rash is sunburn from water reflection around the sunglasses?" "I have a sunburn? Yea, probably." Malar rash removed, Lupus removed from DDx. No ANA test, no RF test. No un-necessary billing.

Was a complete history on this patient better than missing something? Absolutely.



But, for sake of discussion... the #8 cause (firearms) is minor. Thus, along the same lines, the #7 cause (septicaemia) is also minor... so we should stop screening for firearms... and stop screening for bacterial infection? No. I don't think so. Medically, do you?


The firearm is not a CAUSE. I cannot blame my keyboard when I mistype a word in a paper. Sepsis however IS a cause. There is no legitimate medical/nursing/healthcare reason to screen for firearm ownership as if it damages health like high blood pressure will. No amount of strawman arguments will change that.


I find it highly unlikely that a 2 yr old who has an accidental discharge that kills him or herself is to be blamed. I rather think that, yes, in this case, the firearm is to be blamed. Or the parents. Which is generally who is counselled, as 2 yr olds tend to have a very poor memory... As to the rest, see above. History, as you know, is the most important aspect of forming a DDx. The more history, the better the DDx.
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Re: Tennessee Legislation 2012

Postby SomeGuy » Tue Jan 24, 2012 11:45 pm

How many doctors do you think follow, rigidly, the guidelines of the AAP?


Enough that we are having this conversation.

I'm disagreeing with you on how we should approach the issue.


Then do tell, what exactly would you do? We can go around and around as you noted before, but it will drift far from the topic. My position is unchanged, the routine questioning by providers of whether or not patient's own firearms ought to be banned. (Having read your posts and considered your differing views, I would be willing to compromise, and accept a ban on the advice being given that patients dispose of firearms, and the education that they are bad.This would leave allowing them to ask if they own/hunt etc for legitimate purposes, but forbid them to use their position to advocate firearm disarmament. Punishment would be done via licensure and fines, not criminal. It strikes me as quite reasonable to say that it is unprofessional conduct and/or acting outside the scope of practice to advocate removal of firearms from the home, or to tell patients how to store them. I think this compromise would protect both firearm owners and allow provider to still check the box acknowledging it was discussed, though I still would rather it was not mentioned without a true and legit cause.)

But firearms accidents still rank near things we still screen for. So saying that it is minor and we shouldn't screen, but believing that something further down the list that is also minor should be screened for, is doing exactly the same thing as our opponents, just on the other side of the spectrum. We should screen for all of them


How exactly do we screen FOR firearm accidents? You cannot, but you can screen firearm ownership, which medical providers have no business casually screening for. Conversely, we can in fact screen for the prescence of high blood pressure, infection and other medical problems.

You do have conscious control over portion sizes, exercise, what you eat, what you don't eat and everything that leads to a great number of maladies. You don't believe lack of exercise (often conscious), poor diet (often conscious) and not having self control over how much carbs you ingest doesn't play a major role in development of Type II DM? You don't believe that life choices and life style play a huge role in not only progression, onset and outcome of several rather common disease states? A person who chooses to use lots of salt on their meals, because they think it tastes good and thus thinks it a good idea, consciously decided to do something bad for themselves. They exhibited every single stage that the person committing suicide did, except maybe mental anguish. Instead they got pleasure and malignant hypertension, not death.

Now, there are a lot of issues with cholesterol that are not conscious, but are instead genetic. There are lots of issues with BP that are not conscious decisions. There are lots of disease states that cannot be prevented. Which is why so much emphasis is placed on those that can be prevented. I thought you handled your suicide example beautifully. You were direct in your question, when asking if they were going to hurt themselves, instead of beating around the bush. You didn't put a thought into their head and you handled it the exact way the crisis center would. And you are absolutely correct, suicide prevention is not firearms prevention. Just as nutritional counselling is not hypertension prevention. But there is still nutritional counselling. In suicide intervention, you are not looking to limit unintentional acts. In firearms counselling, you are trying to raise awareness of the unintentional action. Again, in the common sense approach. Therefore, it does have a role. It does not a role in eliminating death by suicide, death by homicide, or death by unintentional action, it merely serves as a tool in the overall picture.


It is a stretch to say that a person choosing nutritional options poorly is making the same decisions as a suicidal person. Considering where heart disease for example ranks, nutritional screening has a place of importance. Screening for firearm ownership does not prevent suicide or homicide, and unintentional deaths are very few. You are correct when you say nutritional counseling is not HTN prevention, but nutrional counseling can play a hand in diabetes prevention (or control), cardiovascular health, and more. Knowing a patient owns a firearm does not help us prevent suicide. Knowing the patient's mental health status might, but is a different and legitimate screen. Homicide? Unless you believe owning a gun automatically leads to gang activity, vigilante activity, or other dangerous firearm related behavior, again, no legitimacy. Routine firearm screening does not serve any legitimate purpose.

Consider the patient who comes into your office with complaints of generalized joint pain, has a malar like rash on his face and hearing loss that lateralizes, though no obstruction is noted. Can you think of a scenario where knowing that this patient owns firearms will help exclude a very costly test (~$850) from your differential?

I can. It is a bit contrived, but follow for fun. Bob, 23, comes into the clinic with CC polyarthritis. During history, pt reports family history of rheumatoid arthritis on maternal side. Patient states joint pain is 1 month duration, and denies any other abnormalities. A red rash is noted sub-orbitally extending across the nose. Pt is advised that condition is not chronic, but due to family history and lupus like face rash, coupled with hearing loss, it is suggested that the patient have ANA and RF testing. Due to cost effective nature of doing these two tests in a panel, we order the panel. $850 billed.

ANA negative. RF negative. Insurance cost $850 test+$40 office visit, patient co-pay $350.

Now, if I said, "Do you own guns?" and he replied "Yea, I duck hunt, just got back this weekend." I would have asked, "Did you wear ear protection" "No, was in a blind and needed to communicate with friends." Hearing loss acute, removed from symptoms. "Did you wear any sunscreen?" "No, just these sunglasses." "So that rash is sunburn from water reflection around the sunglasses?" "I have a sunburn? Yea, probably." Malar rash removed, Lupus removed from DDx. No ANA test, no RF test. No un-necessary billing.

Was a complete history on this patient better than missing something? Absolutely.


You didn't have to ask me to follow for fun. I always have enjoyed scenarios like this (especially clear, and concise ones like you gave us), and am silently thankful that my FNP program teaches/tests using this manner often. I don't know what your practice is, but feel free to use scenarios all the time, I enjoy reading them (really, I do), and following the thought process as they get treated.

That said, let us consider your scenario. Could it have been used under my proposed ban on routine firearm screening? Yes. You are not simply screening for firearm ownership, you are seeing if he engaged in any activity that could have caused these signs and symptoms. If you chose to not bring up the firearms, or were unsure yourself where he came from, a more general "Did you do anything in the last week that put you in a lot of sun/around loud noises and how were you protected?" As you can see, a complete history can still be achieved without questioning about guns directly (though again, I say focused questions based on signs/symptoms would/should not be banned. Patient has CC of hearing loss, acute, nothing else, of course it would be reasonable to inquire about loud music/equipment/firearms/angry wife, etc...)

Given our conversation, let me ask, are you concerned that a proposal to forbid providers screening for firearms would inhibit them from providing their services?

I find it highly unlikely that a 2 yr old who has an accidental discharge that kills him or herself is to be blamed. I rather think that, yes, in this case, the firearm is to be blamed. Or the parents. Which is generally who is counselled, as 2 yr olds tend to have a very poor memory... As to the rest, see above. History, as you know, is the most important aspect of forming a DDx. The more history, the better the DDx.


I would think the parents. The gun did not set itself down, plan or in any way decide to kill. The parent was however negligent. When a child drowns in a tub after all, we do not blame H2O. As to the importance of a good history, well, you won't have any argument with me concerning that. Thankfully banning providers from routine firearm screening does not interfere with it.
J. E. F. II, MSN, RN.
SomeGuy
 
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Re: Tennessee Legislation 2012

Postby fl0at » Wed Jan 25, 2012 2:52 pm

SomeGuy wrote:
How many doctors do you think follow, rigidly, the guidelines of the AAP?


Enough that we are having this conversation.

I'm disagreeing with you on how we should approach the issue.


Then do tell, what exactly would you do? We can go around and around as you noted before, but it will drift far from the topic. My position is unchanged, the routine questioning by providers of whether or not patient's own firearms ought to be banned. (Having read your posts and considered your differing views, I would be willing to compromise, and accept a ban on the advice being given that patients dispose of firearms, and the education that they are bad.This would leave allowing them to ask if they own/hunt etc for legitimate purposes, but forbid them to use their position to advocate firearm disarmament. Punishment would be done via licensure and fines, not criminal. It strikes me as quite reasonable to say that it is unprofessional conduct and/or acting outside the scope of practice to advocate removal of firearms from the home, or to tell patients how to store them. I think this compromise would protect both firearm owners and allow provider to still check the box acknowledging it was discussed, though I still would rather it was not mentioned without a true and legit cause.)


Agree with all above, and that is the approach I would prefer. It sets limits and scope.

But firearms accidents still rank near things we still screen for. So saying that it is minor and we shouldn't screen, but believing that something further down the list that is also minor should be screened for, is doing exactly the same thing as our opponents, just on the other side of the spectrum. We should screen for all of them


How exactly do we screen FOR firearm accidents? You cannot, but you can screen firearm ownership, which medical providers have no business casually screening for. Conversely, we can in fact screen for the prescence of high blood pressure, infection and other medical problems.


How do you test for SA infection? You culture. How do you test for firearms? You ask.

Name three tests that are tests of exclusion, not confirmation. Asking about firearms is viewed as a test of exclusion (which I think is wrong, because under a common sense approach, where we look to increase awareness and knowledge, firearms can be found elsewhere). Do you have them? No. So we're going to say you aren't as likely to have an accidental discharge. Do you have them? Yes. So now we are going to just assume everyone with firearms shoots themselves, and warn you to then keep them out of reach, unloaded, locked, separated, or however the practitioner approaches the issue.

That is how you screen for firearm accidents. Now, let me ask you: Is it a sensitive or specific test? Meaning, are you looking to rule in or rule out a situation.

You do have conscious control over portion sizes, exercise, what you eat, what you don't eat and everything that leads to a great number of maladies. You don't believe lack of exercise (often conscious), poor diet (often conscious) and not having self control over how much carbs you ingest doesn't play a major role in development of Type II DM? You don't believe that life choices and life style play a huge role in not only progression, onset and outcome of several rather common disease states? A person who chooses to use lots of salt on their meals, because they think it tastes good and thus thinks it a good idea, consciously decided to do something bad for themselves. They exhibited every single stage that the person committing suicide did, except maybe mental anguish. Instead they got pleasure and malignant hypertension, not death.

Now, there are a lot of issues with cholesterol that are not conscious, but are instead genetic. There are lots of issues with BP that are not conscious decisions. There are lots of disease states that cannot be prevented. Which is why so much emphasis is placed on those that can be prevented. I thought you handled your suicide example beautifully. You were direct in your question, when asking if they were going to hurt themselves, instead of beating around the bush. You didn't put a thought into their head and you handled it the exact way the crisis center would. And you are absolutely correct, suicide prevention is not firearms prevention. Just as nutritional counselling is not hypertension prevention. But there is still nutritional counselling. In suicide intervention, you are not looking to limit unintentional acts. In firearms counselling, you are trying to raise awareness of the unintentional action. Again, in the common sense approach. Therefore, it does have a role. It does not a role in eliminating death by suicide, death by homicide, or death by unintentional action, it merely serves as a tool in the overall picture.


It is a stretch to say that a person choosing nutritional options poorly is making the same decisions as a suicidal person. Considering where heart disease for example ranks, nutritional screening has a place of importance. Screening for firearm ownership does not prevent suicide or homicide, and unintentional deaths are very few. You are correct when you say nutritional counseling is not HTN prevention, but nutrional counseling can play a hand in diabetes prevention (or control), cardiovascular health, and more. Knowing a patient owns a firearm does not help us prevent suicide. Knowing the patient's mental health status might, but is a different and legitimate screen. Homicide? Unless you believe owning a gun automatically leads to gang activity, vigilante activity, or other dangerous firearm related behavior, again, no legitimacy. Routine firearm screening does not serve any legitimate purpose.


You understand the concept of targeted approach, right? Is there a medically legitimate purpose to testing the cranial nerves? Absolutely. Is there a medically legitimate purpose for testing the cranial nerves for someone with a sore toe? Not really. That is the sole idea behind screening. To determine one set where X is important, and one set where Y, conversely, is important. If I screen you for firearms ownership, I can, at least, be pretty certain you own firearms. Whether that becomes important information later, or not, I cannot say. If I could predict the future, I wouldn't have to work.

Consider the patient who comes into your office with complaints of generalized joint pain, has a malar like rash on his face and hearing loss that lateralizes, though no obstruction is noted. Can you think of a scenario where knowing that this patient owns firearms will help exclude a very costly test (~$850) from your differential?

I can. It is a bit contrived, but follow for fun. Bob, 23, comes into the clinic with CC polyarthritis. During history, pt reports family history of rheumatoid arthritis on maternal side. Patient states joint pain is 1 month duration, and denies any other abnormalities. A red rash is noted sub-orbitally extending across the nose. Pt is advised that condition is not chronic, but due to family history and lupus like face rash, coupled with hearing loss, it is suggested that the patient have ANA and RF testing. Due to cost effective nature of doing these two tests in a panel, we order the panel. $850 billed.

ANA negative. RF negative. Insurance cost $850 test+$40 office visit, patient co-pay $350.

Now, if I said, "Do you own guns?" and he replied "Yea, I duck hunt, just got back this weekend." I would have asked, "Did you wear ear protection" "No, was in a blind and needed to communicate with friends." Hearing loss acute, removed from symptoms. "Did you wear any sunscreen?" "No, just these sunglasses." "So that rash is sunburn from water reflection around the sunglasses?" "I have a sunburn? Yea, probably." Malar rash removed, Lupus removed from DDx. No ANA test, no RF test. No un-necessary billing.

Was a complete history on this patient better than missing something? Absolutely.


You didn't have to ask me to follow for fun. I always have enjoyed scenarios like this (especially clear, and concise ones like you gave us), and am silently thankful that my FNP program teaches/tests using this manner often. I don't know what your practice is, but feel free to use scenarios all the time, I enjoy reading them (really, I do), and following the thought process as they get treated.

That said, let us consider your scenario. Could it have been used under my proposed ban on routine firearm screening? Yes. You are not simply screening for firearm ownership, you are seeing if he engaged in any activity that could have caused these signs and symptoms. If you chose to not bring up the firearms, or were unsure yourself where he came from, a more general "Did you do anything in the last week that put you in a lot of sun/around loud noises and how were you protected?" As you can see, a complete history can still be achieved without questioning about guns directly (though again, I say focused questions based on signs/symptoms would/should not be banned. Patient has CC of hearing loss, acute, nothing else, of course it would be reasonable to inquire about loud music/equipment/firearms/angry wife, etc...)

Given our conversation, let me ask, are you concerned that a proposal to forbid providers screening for firearms would inhibit them from providing their services?


Because, quite simply, my initial thought on the rash and the joint pain is not that something external caused both, my thought is that something internal caused both. Could I go through every possible scenario? Sure. It would take forever. But I don't have time to do that, and I don't know what piece of information is going to be important. The point, then, is not that specifically asking about firearms is important. The point was more along the lines of not knowing what is important, and thus not limiting the ability to elicit information that may be helpful.

Now, if I thought the rash was sunburn, if I thought the hearing issue was transient, and I thought the polyarthritis was just acute, maybe I ask exactly how you phrased it, because it means I'm asking an open-ended question, and can get more information out without having to do specifics. But if I get a paranoid patient who is going to lie to me because he thinks I think guns are evil, or just marks "No" on some of the questionnaire forms, because he/she thinks that what I'm asking isn't medically relevant, then we have a problem. Because I don't know what is medically relevant, and the patient doesn't either. That was my point. Not that I need to specifically ask about firearms, but I do need something to clue me in, so that maybe it does strike me as pertinent.

But I agree, when it is relevant, we should be able to ask, and that new proposed law allows for that. My question, through that scenario, was an attempt to get you to see that you do not always know what is relevant and what isn't. So let me ask you, in your proposed method, how do you determine whether something is relevant or not? What clues you in, in the encounter, to ask, other than the obvious, which would be suicide and homicide?

I find it highly unlikely that a 2 yr old who has an accidental discharge that kills him or herself is to be blamed. I rather think that, yes, in this case, the firearm is to be blamed. Or the parents. Which is generally who is counselled, as 2 yr olds tend to have a very poor memory... As to the rest, see above. History, as you know, is the most important aspect of forming a DDx. The more history, the better the DDx.


I would think the parents. The gun did not set itself down, plan or in any way decide to kill. The parent was however negligent. When a child drowns in a tub after all, we do not blame H2O. As to the importance of a good history, well, you won't have any argument with me concerning that. Thankfully banning providers from routine firearm screening does not interfere with it.

[/quote]

Again, like I said, we counsel the parent, not the child. This is no different than saying maintain weapon retention. And, we screen and counsel on drowning in the tub, as well. I'm not saying the weapon is to blame, I'm saying it is either the weapon or the parents. And since I'm counselling the parents, not the weapon, I felt you would pick up on the fact that it was the parents fault, and thus we should counsel the parents. We can't do that without screening. Or, I mean we can, we just counsel everyone on firearms. Which will become the new norm, if we aren't allowed to target for it. If you think, for one instance, that not being able to ask about firearms will prevent providers from just counselling everyone on firearms, I believe you will be quite surprised. In other words, people who don't own guns but have no reason to think twice about getting one, will now be getting negative representation from every Peds doc they see, and it might sway their opinion. And I bet you this is the future. No more screening, just straight agenda. No more agenda after a checked yes... just straight agenda for everyone, equally.

As to the history: so far, it hasn't. Can you, with conviction, state that banning of that screening will always, and forever, provide no use to you, ever? And you can answer yes, here, and that is fine. But I will answer no, because I don't know what is going to be important. I think it will be pretty far down on the list of important pieces of information, but I can't say that it will never be important. I just don't know.
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Re: Tennessee Legislation 2012

Postby SomeGuy » Wed Jan 25, 2012 3:57 pm

Agree with all above, and that is the approach I would prefer. It sets limits and scope.


Just to be clear, I am advocating a banning on routine questioning about firearm ownership. I note further on in your post you once again return to defending such.

How do you test for SA infection? You culture. How do you test for firearms? You ask.


This makes the assumption that firearms are by their very presence as dangerous as a staph aureus infection.

Do you have them? Yes. So now we are going to just assume everyone with firearms shoots themselves, and warn you to then keep them out of reach, unloaded, locked, separated, or however the practitioner approaches the issue.

That is how you screen for firearm accidents. Now, let me ask you: Is it a sensitive or specific test? Meaning, are you looking to rule in or rule out a situation.


Probably not the best assumption to make, given that using the statistic from earlier we know that it is a very small, quite tiny minority that in fact shoots themselves. To use your culturing analogy, this is like doing rapid strep tests and blood cultures on well child visits with no signs or symptoms of distress.

To answer your question, it appears to be ruling in.

You understand the concept of targeted approach, right? Is there a medically legitimate purpose to testing the cranial nerves? Absolutely. Is there a medically legitimate purpose for testing the cranial nerves for someone with a sore toe? Not really. That is the sole idea behind screening. To determine one set where X is important, and one set where Y, conversely, is important. If I screen you for firearms ownership, I can, at least, be pretty certain you own firearms. Whether that becomes important information later, or not, I cannot say. If I could predict the future, I wouldn't have to work.


Keep in mind, under my proposal, it would not be forbidden with cause. What legitimate medical purpose is served by simply knowing who owns guns, for later use? Worse, as others have mentioned, as health records are computerized and made more accessable, do we really want it to be something placed in yet another database where another infringement can occur?

The point was more along the lines of not knowing what is important, and thus not limiting the ability to elicit information that may be helpful.


Actually, my proposal would not limit this. Consider the progress note: "Patient complained of hearing loss on one side occuring after this weekend, reported firing guns without hearing protection when asked." In this scenario, it is obviously not routine, and the cause is right there and justifiable. I have yet to hear anyone support a blanket and complete forbidding of talking about guns, the point is to prevent the casual, routine questioning about firearms and to prohibit the misuse of the health care profession as a platform to advocate disarmament.

But if I get a paranoid patient who is going to lie to me because he thinks I think guns are evil, or just marks "No" on some of the questionnaire forms, because he/she thinks that what I'm asking isn't medically relevant, then we have a problem.


Patient dishonesty is always a problem, however, using your example here, how would this patient interview be made better by a direct 'do you have guns' question? I would wager my open ended question might work a lot better in this situation.

But I agree, when it is relevant, we should be able to ask, and that new proposed law allows for that. My question, through that scenario, was an attempt to get you to see that you do not always know what is relevant and what isn't. So let me ask you, in your proposed method, how do you determine whether something is relevant or not? What clues you in, in the encounter, to ask, other than the obvious, which would be suicide and homicide?


The method I have used as an RN, and that my FNP program encourages are open ended questions. Think of a conversation as a giant tree. Open ended questions allow cutting of whole branches, direct questions are for trimming a single branch. As for suicide/homicide clues, that would be something I ought to gather during the assessment on mental health. The specific question I typically use is "Do you have thoughts about hurting yourself, or others?" Not the most open question, but it has been very effective at getting a hand on whether a person plans to hurt him/herself or others. I have found patients to be very honest with that question. No need to delve into firearms.

Again, like I said, we counsel the parent, not the child. This is no different than saying maintain weapon retention. And, we screen and counsel on drowning in the tub, as well. I'm not saying the weapon is to blame, I'm saying it is either the weapon or the parents. And since I'm counselling the parents, not the weapon, I felt you would pick up on the fact that it was the parents fault, and thus we should counsel the parents. We can't do that without screening. Or, I mean we can, we just counsel everyone on firearms. Which will become the new norm, if we aren't allowed to target for it. If you think, for one instance, that not being able to ask about firearms will prevent providers from just counselling everyone on firearms, I believe you will be quite surprised. In other words, people who don't own guns but have no reason to think twice about getting one, will now be getting negative representation from every Peds doc they see, and it might sway their opinion. And I bet you this is the future. No more screening, just straight agenda. No more agenda after a checked yes... just straight agenda for everyone, equally.


I actually think you are correct, which is why the agenda would also be forbidden. A pediatrician who used his office to advocate removing all firearms from the home "just because" would be subject to discipline under my proposal. If the pediatrician wanted to advocate firearm safety, it would need to be done minus an agenda. "If you own guns, store them safely" would be acceptable. This would be right on the level of "Avoid choking hazards". No agenda, not pushing removal, merely reminding parents to keep the environment safe for children.

As to the history: so far, it hasn't. Can you, with conviction, state that banning of that screening will always, and forever, provide no use to you, ever? And you can answer yes, here, and that is fine. But I will answer no, because I don't know what is going to be important. I think it will be pretty far down on the list of important pieces of information, but I can't say that it will never be important. I just don't know.


With respect, your question is not accurate. I am not for banning them from ever asking, I am for banning them from routinely asking. This was exactly what I proposed as a compromise that sets limit and scope that you said you would prefer.
J. E. F. II, MSN, RN.
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Re: Tennessee Legislation 2012

Postby fl0at » Wed Jan 25, 2012 7:16 pm

SomeGuy wrote:
Agree with all above, and that is the approach I would prefer. It sets limits and scope.


Just to be clear, I am advocating a banning on routine questioning about firearm ownership. I note further on in your post you once again return to defending such.

How do you test for SA infection? You culture. How do you test for firearms? You ask.


This makes the assumption that firearms are by their very presence as dangerous as a staph aureus infection.


SA is not, by itself, a dangerous organism. A firearm is not by itself a dangerous instrument. An uncontrolled infection of SA, or a failure of the immune system to clear SA, or SA ending up in otherwise sterile tissue... is an issue. If you cultured your nose, right now, you'd likely find SA. Thus, is SA infection inherently dangerous? No. It is when things go wrong that becomes an issue. Some of your views are rather interesting, in regards to medicine. Especially considering that you, yourself, might even harbour MRSA. Both are not dangerous, to most people. Both can be dangerous, to some people.

I'm not defending routine screening, I'm just saying it has its purposes. I don't like completely eliminating things, but if I have to take an all or none approach, I'd rather have it and not need it, than need it and not have it. Which is a pretty good defence for having a carry permit in the first place, right? So, and try to not misconstrue this point, I'm not advocating for everyone to screen, I'm advocating for my ability to do so should I want to.

Do you have them? Yes. So now we are going to just assume everyone with firearms shoots themselves, and warn you to then keep them out of reach, unloaded, locked, separated, or however the practitioner approaches the issue.

That is how you screen for firearm accidents. Now, let me ask you: Is it a sensitive or specific test? Meaning, are you looking to rule in or rule out a situation.


Probably not the best assumption to make, given that using the statistic from earlier we know that it is a very small, quite tiny minority that in fact shoots themselves. To use your culturing analogy, this is like doing rapid strep tests and blood cultures on well child visits with no signs or symptoms of distress.

To answer your question, it appears to be ruling in.


That point does have merit, so let's expand upon it. Since I know I'm likely to find several normal flora pathogens, in normal levels, I don't need to do the test. How do I know if I'm going to find normal levels of firearms, if I don't ask?

You understand the concept of targeted approach, right? Is there a medically legitimate purpose to testing the cranial nerves? Absolutely. Is there a medically legitimate purpose for testing the cranial nerves for someone with a sore toe? Not really. That is the sole idea behind screening. To determine one set where X is important, and one set where Y, conversely, is important. If I screen you for firearms ownership, I can, at least, be pretty certain you own firearms. Whether that becomes important information later, or not, I cannot say. If I could predict the future, I wouldn't have to work.


Keep in mind, under my proposal, it would not be forbidden with cause. What legitimate medical purpose is served by simply knowing who owns guns, for later use? Worse, as others have mentioned, as health records are computerized and made more accessable, do we really want it to be something placed in yet another database where another infringement can occur?


This is more along the lines of epidemiology, and tracing, and again, another contrived scenario, but if you have several patients that come in with fungal infections, and have no obvious link, meaning, they are all different ages, sexes, background, education, life style, etc, and you are trying to figure out why in the world you've had a sudden outbreak of fungal infections, it might be interesting to have more information to tie all those individuals together. Maybe something that is unique, like firearm ownership. They were all at the same range, that was being dug up, and aerosoled the pathogen, and it was inhaled.

I mean, the scenario is contrived, and would never, ever, ever, occur, but why limit the information you can obtain simply because the probability is minuscule? This, obviously, would be akin to asking everyone if they go to Walmart, or TGI Friday's, or own a soccer ball, which would be rather ridiculous, but nobody is attempting to ban asking that question, or only asking that question with cause.

Can you name any other question that has been banned, even without cause, from the interview, or on a screening form? I can't think of any. And we're talking about STDs, genetic disorders, smokers, people who've been jailed before, unnatural sexual acts... all capable of being exploited. Some of them with way more exploitation potential than whether I own a firearm, or not. Some of them are exploited, by insurance... and we are still able to ask about them.


The point was more along the lines of not knowing what is important, and thus not limiting the ability to elicit information that may be helpful.


Actually, my proposal would not limit this. Consider the progress note: "Patient complained of hearing loss on one side occuring after this weekend, reported firing guns without hearing protection when asked." In this scenario, it is obviously not routine, and the cause is right there and justifiable. I have yet to hear anyone support a blanket and complete forbidding of talking about guns, the point is to prevent the casual, routine questioning about firearms and to prohibit the misuse of the health care profession as a platform to advocate disarmament.


I get that, I do. For epidemiology purposes, I don't mind having more information. Useful or not. I especially don't want more laws. I like less laws. I really don't want laws telling me what I can and cannot ask. I prefer that if you don't like what I'm asking, to seek someone else.

But if I get a paranoid patient who is going to lie to me because he thinks I think guns are evil, or just marks "No" on some of the questionnaire forms, because he/she thinks that what I'm asking isn't medically relevant, then we have a problem.


Patient dishonesty is always a problem, however, using your example here, how would this patient interview be made better by a direct 'do you have guns' question? I would wager my open ended question might work a lot better in this situation.


Patients respond better to direct questioning in most situations. Do you beat around the bush when you ask if they've been in jail? What about drug use? Are you open ended in suicide questions? What about STDs? Asking about cheating on the spouse?

When, when asking about private, intimate and personal details, are you ever less direct? If you maintain asking about firearms is personal, I maintain doing so directly is better, in most situations. Having that doctor-patient relationship, though, will allow the provider to determine for which patients non-direct questions are better. But in most cases, direct questioning on personal matters is better.

But I agree, when it is relevant, we should be able to ask, and that new proposed law allows for that. My question, through that scenario, was an attempt to get you to see that you do not always know what is relevant and what isn't. So let me ask you, in your proposed method, how do you determine whether something is relevant or not? What clues you in, in the encounter, to ask, other than the obvious, which would be suicide and homicide?


The method I have used as an RN, and that my FNP program encourages are open ended questions. Think of a conversation as a giant tree. Open ended questions allow cutting of whole branches, direct questions are for trimming a single branch. As for suicide/homicide clues, that would be something I ought to gather during the assessment on mental health. The specific question I typically use is "Do you have thoughts about hurting yourself, or others?" Not the most open question, but it has been very effective at getting a hand on whether a person plans to hurt him/herself or others. I have found patients to be very honest with that question. No need to delve into firearms.


That question is not open-ended. That is direct questioning. It is yes or no. And to expand, you know very well that if a person gives off the vibe of suicide, you don't beat around the bush. You directly question whether they are thinking about suicide. Have you done crisis training? I assume so. Then you know that you are always direct with that question.

Again, like I said, we counsel the parent, not the child. This is no different than saying maintain weapon retention. And, we screen and counsel on drowning in the tub, as well. I'm not saying the weapon is to blame, I'm saying it is either the weapon or the parents. And since I'm counselling the parents, not the weapon, I felt you would pick up on the fact that it was the parents fault, and thus we should counsel the parents. We can't do that without screening. Or, I mean we can, we just counsel everyone on firearms. Which will become the new norm, if we aren't allowed to target for it. If you think, for one instance, that not being able to ask about firearms will prevent providers from just counselling everyone on firearms, I believe you will be quite surprised. In other words, people who don't own guns but have no reason to think twice about getting one, will now be getting negative representation from every Peds doc they see, and it might sway their opinion. And I bet you this is the future. No more screening, just straight agenda. No more agenda after a checked yes... just straight agenda for everyone, equally.


I actually think you are correct, which is why the agenda would also be forbidden. A pediatrician who used his office to advocate removing all firearms from the home "just because" would be subject to discipline under my proposal. If the pediatrician wanted to advocate firearm safety, it would need to be done minus an agenda. "If you own guns, store them safely" would be acceptable. This would be right on the level of "Avoid choking hazards". No agenda, not pushing removal, merely reminding parents to keep the environment safe for children.


And I agree here. I would just like to keep screening, or at least keep the option of keeping the screening. Now, if your patient asks "How do I store them safely?" how do you respond? "I'm sorry, I'm not qualified to answer that question." Then why the hell did you advise it, if you can't even give me your opinion on what is "safely stored?"

As to the history: so far, it hasn't. Can you, with conviction, state that banning of that screening will always, and forever, provide no use to you, ever? And you can answer yes, here, and that is fine. But I will answer no, because I don't know what is going to be important. I think it will be pretty far down on the list of important pieces of information, but I can't say that it will never be important. I just don't know.


With respect, your question is not accurate. I am not for banning them from ever asking, I am for banning them from routinely asking. This was exactly what I proposed as a compromise that sets limit and scope that you said you would prefer.


Fair enough. It will be the first ever question banned from routine screening, but why not. Law has taken over medicine anyway, might as well just have one more.
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Re: Tennessee Legislation 2012

Postby GKar » Thu Jan 26, 2012 1:13 pm

EDIT: sorry, got my bill numbers mixed up. Carry on!
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Re: Tennessee Legislation 2012

Postby SomeGuy » Thu Jan 26, 2012 11:37 pm

I'm not defending routine screening, I'm just saying it has its purposes. I don't like completely eliminating things, but if I have to take an all or none approach, I'd rather have it and not need it, than need it and not have it. Which is a pretty good defence for having a carry permit in the first place, right? So, and try to not misconstrue this point, I'm not advocating for everyone to screen, I'm advocating for my ability to do so should I want to.


What it sounds like, is that you want the ability, if you needed it, something I am quite fine with leaving.

How do I know if I'm going to find normal levels of firearms, if I don't ask?


And what, do tell, would be a "normal" level of firearms? What if a patient has the wrong number?

This is more along the lines of epidemiology, and tracing, and again, another contrived scenario, but if you have several patients that come in with fungal infections, and have no obvious link, meaning, they are all different ages, sexes, background, education, life style, etc, and you are trying to figure out why in the world you've had a sudden outbreak of fungal infections, it might be interesting to have more information to tie all those individuals together. Maybe something that is unique, like firearm ownership. They were all at the same range, that was being dug up, and aerosoled the pathogen, and it was inhaled.

I mean, the scenario is contrived, and would never, ever, ever, occur, but why limit the information you can obtain simply because the probability is minuscule?


I think that would be asking with reason. Not just routinely asking because you felt like it. If you thought in some manner firearms were the source of a legitimate medical issue, it would be reasonable to ask. To give you a more plausaible scenario, we can assume poor venting of an indoor range cause legionella, if you want to continue this path.

Can you name any other question that has been banned, even without cause, from the interview, or on a screening form? I can't think of any. And we're talking about STDs, genetic disorders, smokers, people who've been jailed before, unnatural sexual acts... all capable of being exploited. Some of them with way more exploitation potential than whether I own a firearm, or not. Some of them are exploited, by insurance... and we are still able to ask about them.


Believe it or not, I am not happy that things came to this. Consider though, the health care professionals had the dignity to not abuse or exploit any of the myriad other areas we have been trusted with. It actually saddens me that there are people willing to allow our noble professions to be abused in such a manner. To a degree, we are in fact maintaining the quality of the profession by forbidding such activity. My proposal even maintains the dignity of the profession by making it something that can be handled internally, instead of a DA prosecuting providers, I would have the punishments meted out by the Boards regulating the various professions.

I especially don't want more laws. I like less laws. I really don't want laws telling me what I can and cannot ask. I prefer that if you don't like what I'm asking, to seek someone else.


I find myself in agreement with the first part. I actually have encouraged the latter before. I think I could summarize our agreement in a nutshell, I find the need for this distasteful but present, you find it distateful, and do not see the same need. Is that accurate?

Patients respond better to direct questioning in most situations.


That may be, however the situation you described I responded to had a patient who did not trust you, and was willing to lie to avoid the answer. What purpose does directly inquiring about firearm ownership achieve in your situation? In your situation an open ended question may avoid eliciting a paranoid and false response. In the scenario you described, an open ended question is likely to yield more than a direct question.

That question is not open-ended. That is direct questioning. It is yes or no. And to expand, you know very well that if a person gives off the vibe of suicide, you don't beat around the bush. You directly question whether they are thinking about suicide. Have you done crisis training? I assume so. Then you know that you are always direct with that question.


Actually, the question I proposed, that I myself acknowledged was not the most open ended, was exactly what we were taught to use. Refer back to my suicide example earlier, I think you will see the similarities. (Note: the example earlier follows directly after this question I used.)

Now, if your patient asks "How do I store them safely?" how do you respond? "I'm sorry, I'm not qualified to answer that question." Then why the hell did you advise it, if you can't even give me your opinion on what is "safely stored?"


Assuming you intend to tell patients to store them safely, the wisest course of action (or more accurately, the one that holds the least bias) would be to acknowledge there are different opinions, the NRA probably has some advice, and it would also be OK in my eyes to acknowledge what the AAP says; the difference in this approach is it removes the rabid activism of the AAP and places it in a bin of ideas, and not as the sole solution.

Better solution (and my plan): Don't touch it. I won't even bother with a "store guns safely" comment, and I plan to carry in the office, and once I own my own office I probably will openly carry (or at least OWB under a lab coat that is open).

Fair enough. It will be the first ever question banned from routine screening, but why not. Law has taken over medicine anyway, might as well just have one more.


To the former, it will also be providers own fault. If pediatricians routinely gave small children sexual advice, and went so far as to tell parents what clothes not to even keep in the house, I think the backlash would be strong as well. It was never an issue before because health care professionals weren't disgracing themselves. As to the control law has placed, my observations tell me insurance agencies and what they will pay for (and the same from the FedGov) is what really determines what happens in medicine. I could not begin to count the number of times a Case Manager came to me and told me we needed X order or whatnot for insurance purposes. No, if an orthopedic surgeon orders a rolling walker for a patient who had a knee or hip replacement, his order is insufficient. We must have our forms!
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Re: Tennessee Legislation 2012

Postby fl0at » Fri Jan 27, 2012 11:20 am

SomeGuy wrote:What it sounds like, is that you want the ability, if you needed it, something I am quite fine with leaving.

How do I know if I'm going to find normal levels of firearms, if I don't ask?


And what, do tell, would be a "normal" level of firearms? What if a patient has the wrong number?


No, I want the ability, period. That doesn't mean I'll use the checkbox on the screening form, but I still want the ability to put it on there. And we can play the 1st Amendment rights game if we want to, and debate the merits of when it is appropriate to limit them, or not, and you'd probably say we can limit them, and I'll say we shouldn't, and you'll give examples of when we have, and I'll disagree with them, and it will come down to this: If you support the 2nd Amendment as written, then you support the 1st Amendment as written, or you are practising hypocrisy. And thus, you don't support laws that limit 1st Amendment rights. And, between you and I, me asking about you owning firearms... doesn't impede on your 2nd Amendment rights. Just me asking in no way interferes with your right to keep and bear arms.

So, logically... the issue is what is done with that information. Thus, that is where the law should be focused, not on a gag order.

And normal levels of firearms are individual specific. I might do a CAGE like screening to see if the guy ever felt like cutting back, by selling me a 1911.

I think that would be asking with reason. Not just routinely asking because you felt like it. If you thought in some manner firearms were the source of a legitimate medical issue, it would be reasonable to ask. To give you a more plausaible scenario, we can assume poor venting of an indoor range cause legionella, if you want to continue this path.


But what tips you off, initially? You are looking at the files on all 6 patients. All different ages, background, etc. How do you identify that distinguishing trait? We culture, we found Legionella, we treated. Only one died. We are awesome. Now, CDC wants to know why. How do you put 2+2 together? Or do you just shrug it off and let CDC investigate it?


I find myself in agreement with the first part. I actually have encouraged the latter before. I think I could summarize our agreement in a nutshell, I find the need for this distasteful but present, you find it distateful, and do not see the same need. Is that accurate?


Correct. But with some minor differences, as noted above.

That may be, however the situation you described I responded to had a patient who did not trust you, and was willing to lie to avoid the answer. What purpose does directly inquiring about firearm ownership achieve in your situation? In your situation an open ended question may avoid eliciting a paranoid and false response. In the scenario you described, an open ended question is likely to yield more than a direct question.


Oddly enough, direct questioning is best when you have someone who might be willing to lie. They don't have time to formulate the lie. Think about any peds visit you've had. Parents in the room, trying to coax your way around the sex, drugs and rock and roll questions... and kid is giving you all the perfect answers. You ask Mom to step out of the room and say: Alright, be straight. You smoke a little weed? Have a sip every now and then?

Kid will be honest with you, more times than not. And this is with an already un-trusting population (Med).


Actually, the question I proposed, that I myself acknowledged was not the most open ended, was exactly what we were taught to use. Refer back to my suicide example earlier, I think you will see the similarities. (Note: the example earlier follows directly after this question I used.)


Yea, it is exactly what they taught you to use, because they teach you to be direct in manner, but not specific. For example, you wouldn't say: "Are you thinking about harming yourself or others... today?"

But I will agree, it is somewhat open ended, because it encourages the patient to talk, but the manner in which the question asked is direct, which is what I'm talking about, or meant to be talking about.


Assuming you intend to tell patients to store them safely, the wisest course of action (or more accurately, the one that holds the least bias) would be to acknowledge there are different opinions, the NRA probably has some advice, and it would also be OK in my eyes to acknowledge what the AAP says; the difference in this approach is it removes the rabid activism of the AAP and places it in a bin of ideas, and not as the sole solution.

Better solution (and my plan): Don't touch it. I won't even bother with a "store guns safely" comment, and I plan to carry in the office, and once I own my own office I probably will openly carry (or at least OWB under a lab coat that is open).


That is not that much different than what already occurs, for the Docs I've worked with; minus the screening.

To the former, it will also be providers own fault. If pediatricians routinely gave small children sexual advice, and went so far as to tell parents what clothes not to even keep in the house, I think the backlash would be strong as well. It was never an issue before because health care professionals weren't disgracing themselves. As to the control law has placed, my observations tell me insurance agencies and what they will pay for (and the same from the FedGov) is what really determines what happens in medicine. I could not begin to count the number of times a Case Manager came to me and told me we needed X order or whatnot for insurance purposes. No, if an orthopedic surgeon orders a rolling walker for a patient who had a knee or hip replacement, his order is insufficient. We must have our forms!


Medicine gave up and gave in to insurance, because offices didn't want to set prices or be burdened with the business of medicine. But more importantly, they didn't want to cause waves. And so medicine is in the position medicine is in... because they don't stand up, they don't make waves, they just take whatever comes down. But I digress.

Paediatricians do routinely screen sexual encounters and give advise on how to dress to girls around sexual age. Especially if the parents don't seem to be.
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Re: Tennessee Legislation 2012

Postby SomeGuy » Fri Jan 27, 2012 8:11 pm

And we can play the 1st Amendment rights game if we want to


Wrong, and for one simple reason, I am not touching your right as a citizen to speak out against firearms, or vote, or spend money on a cause etc. What I am for, is a limitation on what a profession that is regulated by the state, can do. Huge difference.

And normal levels of firearms are individual specific. I might do a CAGE like screening to see if the guy ever felt like cutting back, by selling me a 1911.


So you might have a limit on what you advise certain individuals to have, and limits on what he ought to own? Normal levels of gun ownership is whatever we want it to be. I hope you only mentioned the CAGE type assessment as a joke (supported by the buying a 1911 comment) and not as a thought that practioners ought to assess patients for firearm addiction. (I actually did a CAGE assessment 3 hours ago, while it is very short, I would really hate to ever do one on firearms. I would feel downright dirty.)

But what tips you off, initially?


You are looking at the files on all 6 patients. All different ages, background, etc. How do you identify that distinguishing trait?


If I actually feel like doing investigative work, I ask the patients questions. Simply knowing 6 patients own firearms would not clue me in on this one. In this scenario, I would be asking about places the patient had been the last few weeks. When I started getting multiple patients saying the same indoor gun range, THAT would clue me in.

You ask Mom to step out of the room and say: Alright, be straight. You smoke a little weed? Have a sip every now and then?


Considering this case, is it the direct or indirect question, versus the lack of a parent who may punish them? When dealing with teenagers 1 on 1, I tend to give them a little open air, and they tend to talk pretty readily to me. What I have noticed, is depending upon the culture of the little sub population you are dealing with, they might just lie right to you, regardless of all other factors. However, the honesty of children in selected populations is going a tad bit OT.

That is not that much different than what already occurs, for the Docs I've worked with; minus the screening.


You probably work with docs who represent the vast majority of the physician population: Honest and decent people. As I have said before, I am not happy that I think such measures are needed.

Medicine gave up and gave in to insurance, because offices didn't want to set prices or be burdened with the business of medicine. But more importantly, they didn't want to cause waves. And so medicine is in the position medicine is in... because they don't stand up, they don't make waves, they just take whatever comes down. But I digress.

Paediatricians do routinely screen sexual encounters and give advise on how to dress to girls around sexual age. Especially if the parents don't seem to be.


Digress maybe, but I agree. The path of least resistance was not the best. Sadly now the groups representing physicians (and nurses) are not merely passively standing by, by as far as I can tell, openly walking down the wrong paths. I think that would be another matter entirely though. One I suspect we would find more common ground on.

I didn't say sexual age, I said small children. We won't get into the incredible lack of parenting in many places. I don't think either of us will be kind to them.
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Re: Tennessee Legislation 2012

Postby fl0at » Sat Jan 28, 2012 12:55 am

SomeGuy wrote:Wrong, and for one simple reason, I am not touching your right as a citizen to speak out against firearms, or vote, or spend money on a cause etc. What I am for, is a limitation on what a profession that is regulated by the state, can do. Huge difference.


Lots of things are regulated by the state. I fail to see how this factors into 1st amendment rights. Teachers licenses' are regulated by the state. Are private school teachers allowed to voice opinions on religion in the classroom? Yes. Are private school teachers allowed to voice opinions on firearms? Yes. Are private school teachers allowed to voice their opinion on any other number of issues? Yes.

I don't see why a private doctor's office is any different. I guess I fail to see what regulation by the state has to do with checking 1st amendment rights. Can you elaborate? I'm just not seeing your point of view.

So you might have a limit on what you advise certain individuals to have, and limits on what he ought to own? Normal levels of gun ownership is whatever we want it to be. I hope you only mentioned the CAGE type assessment as a joke (supported by the buying a 1911 comment) and not as a thought that practioners ought to assess patients for firearm addiction. (I actually did a CAGE assessment 3 hours ago, while it is very short, I would really hate to ever do one on firearms. I would feel downright dirty.)


I wouldn't have a limit. I'd probably make an off handed comment that the person should get a shotgun for home protection, especially a pump, because that sound cannot be mistook for any other sound on earth. And then catch a liability issue when dude bought one and blew through his paper thin walled apartment. No thanks. Be way more efficient to just let him know the next TFA meeting and get help on selection there, not the office. Yea, CAGE was a joke. Did you follow up with a RAPS4? I can never remember that one, so I just do CAGE. It isn't as good as RAPS4, though, or so I hear.

If I actually feel like doing investigative work, I ask the patients questions. Simply knowing 6 patients own firearms would not clue me in on this one. In this scenario, I would be asking about places the patient had been the last few weeks. When I started getting multiple patients saying the same indoor gun range, THAT would clue me in.


And that would work, if you were able to ask all your patients. And what would you do if you weren't? It isn't that the firearms ownership would clue you in, just that there was a connection. In an epidemiology study, this would be more important. With CDC, they could actually go out and do the leg work themselves, since it would be unlikely that all the affected patients presented to the same clinic. But, since we are on the EMR kick (for whatever good that is going to do), if you could cross search a database of other new flare ups and compare the record and notice firearms, the only similarity, you might think indoor range (but only because you shoot). This would be useful if you are only getting to see 2 of the 6 patients, and the other comparison is in respiratory distress and not up for much conversation.

But again, highly contrived scenario, considering you might as well also screen everyone for cats, trips to Walmart and the local diner. But, I doubt we'll see that level of EMR any time soon. Be neat, though, instead of waiting on faxes.

Considering this case, is it the direct or indirect question, versus the lack of a parent who may punish them? When dealing with teenagers 1 on 1, I tend to give them a little open air, and they tend to talk pretty readily to me. What I have noticed, is depending upon the culture of the little sub population you are dealing with, they might just lie right to you, regardless of all other factors. However, the honesty of children in selected populations is going a tad bit OT.


Typically the parent. But I've had a few that would lie to me until I was more direct. But at that point, it was probably more of a brow beating instead of how the question was phrased. But I still do the sex, drugs and cheating spouse routine a little more directly than everything else.


I didn't say sexual age, I said small children. We won't get into the incredible lack of parenting in many places. I don't think either of us will be kind to them.


It would be a tad bit awkward to counsel 3 year olds on proper condom use, but man, I wouldn't be surprised if it isn't coming...
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Re: Tennessee Legislation 2012

Postby Tim Nunan » Sat Jan 28, 2012 4:40 pm

'Twould be appreciated if this nitpicking bickering were done by you two via email or phone. It is apparent that one dislikes doctors asking about firearms while the other believes it is in the doctor's purview to do so.
Last edited by Tim Nunan on Sun Jan 29, 2012 11:34 am, edited 1 time in total.
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Re: Tennessee Legislation 2012

Postby fl0at » Sat Jan 28, 2012 5:25 pm

My apologies Tim. Thanks for letting us carry on as long as we did, though.
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