By James D. Felsen
In the wake of Newtown, New York State officials, legislatively, and President Obama, supposedly by giving health personnel new "tools" by executive order, allegedly have prescribed a partial remedy to curb mass social violence. Their "haste makes waste" approach not only represents little more than a placebo but could also contribute to serious disruption and harm.
Ironically, it was physicians, especially pediatricians, who -- reacting to a Florida situation -- recently fought to be allowed to continue to ask parents about home environmental hazards, including guns, which could harm their patients. This plea for voluntary permissiveness in professional practice is beginning to be "twisted" to define a "public safety" interrogation and reporting role for health practitioners that probably is imprudent and potentially harmful.
Although still largely voluntary and discretionary (except for New York), many physicians fear that measures like these could dissuade citizens with potentially violent propensities from seeking medical care or patients, under medical/mental health care, from disclosing (especially recent changes in) "violence" ideations. They could also stifle disclosure and discussion about potential home safety issues and parental and child behavior and practices.
Health professionals are well aware of the existing "Tarasoff "responsibility for disclosure when they believe an individual represents a violent threat. The new actions add little to help or protect health professionals or the public in this regard. Physicians also have had a long time "public safety" collaboration role with DMV, FAA and other entities to protect the public from patients who potentially could cause harm because of medical conditions and limitations.
Physicians share the public's frustration with high health care costs and health status outcomes that are far from optimal and below other industrialized nations (See recent IOM-NRC Report). They also realize that health and cost consequences are often the result of complex socio-economic, behavioral and cultural factors, e.g., violence, substance abuse, high risk/teenage pregnancies, child neglect/abuse, inactivity and obesity, which they have an important, but limited, role in addressing.
Physicians fear this shared frustration will not only result In potentially stifling physician-patient disclosure and interaction, but that an "ask and report" provision will worm its way into mandatory "cookbook" performance criteria and reporting requirements - with not only monetary penalties but legal liability springing from a "Doc should have known" mentality.
For well-trained health professionals, diagnosing health conditions and identifying potential disease/injury risks is not difficult. Predicting -- with any degree of certainty -- which individuals with such diagnoses and risks are going to develop a health condition/injury, die, become disabled or commit a violent act within a defined time period is very, very difficult. It is hard -- and often not possible -- for the best-trained professionals and possibly relegating this poor specificity "labeling" task to less trained health personnel is very problematic.
Our mental health system often is poorly integrated with our other medical care and social systems. Resources for ongoing treatment, outpatient adherence tracking, institutionalization, ancillary, e.g., substance abuse, employment, support are chronically deficient. Drastic improvements needed in these areas are where we need to start if we are to have any chance of reducing violence. These measures will not solve the problem but do far more than the recent placebos that suppose a level of predictive precision that does not exist and carry a high proclivity to cause harm.
Felsen is a retired public health physician who lives in Great Cacapon.