The 16-year-old boy came in with his mom for a routine physical at the Bowdoin Street Health Center in Boston. Dr. Kamau Karanja remembers asking all the usual questions: Did the boy wear a seat belt? How about a bike helmet? How’s school? The boy’s mom spoke up. She told Karanja her son’s grades were slipping and that he’d been coming home late.
“We talked a little bit about referring him to counseling or some way to coordinate with his teachers,” recalls Karanja. He pauses. “I found out about a week later that he had actually been murdered.”
Karanja describes feeling devastated.
“We don’t lose many children in primary care, and this was the first time I had lost someone to, to violence,” says Karanja.
In hindsight, Karanja now sees that the problems in school and coming home late, those were red flags. But what else could Karanja have done? What more should he have asked? In all the debate about whether doctors should screen patients to prevent gun injuries or death, Karanja has stumbled on a key missing piece: What questions might deliver answers that matter?
Slowly, cautiously, Karanja has begun testing some gun-related routine check-up questions with his patients. He started with this: "Have you experienced any violence among family or friends?"
“That wasn’t any good,” says Karanja, “because everyone said 'yes.'” The Bowdoin Street Health Center, part of Beth Israel Deaconess Medical Center, sits in the middle of one of Boston’s gun injury hot spots.
He tried the question: "Do you carry a weapon?" That one didn’t work, Karanja says, “because kids obviously didn’t want to disclose that they may be doing something that could get them in trouble.”
Karanja says he looked for guidance from medical societies about how to screen patients at risk for homicide and found little if anything of use.
So Bowdoin Street, where Karanja is the medical director, went to the source. On a Wednesday evening, 16 members of the health center’s youth leadership program pull chairs into a semi-circle around Alberte Altine-Gibson, the center’s manager of community health. She tells them Dr. Karanja’s story. We’re only using the teens’ first names to guard against any retaliation.
“What we’re going to do tonight is I’m going to ask you some questions,” says Altine-Gibson, pointing to seven written on posters at the front of the room. “I just want to hear your honest feedback, your honest opinion.”
The goal: to find out which questions young people would answer in an exam room — which ones might help save a life.
Altine-Gibson moves toward the first poster and reads the question: "Have you been involved in any fights this year, if so, how many?"
“Show of hands,” she calls out, “how many of you would feel comfortable answering that question if your doctor asked?”
More than half the teen leaders raise a hand. Altine-Gibson points to one young man who does not and asks why.
“I would feel somewhat uncomfortable,” says Jamarri, “because if my doctor’s asking me if I got into a fight, I’d be thinking, oh, am I going to get into trouble?"
“I’d rephrase it,” suggests Tamira, and just ask, “if you’ve been physically hurt from a fight ... has it impacted your health in any way?”
"OK," says Altine-Gibson, nodding. “Let’s say if there was a fight or whatever and they ask you, well, is this issue over, is it done with? Would you feel comfortable answering that question?”
A young woman named Taylor says she isn’t sure if she’d want to answer that one.
“What if, I don’t know, the fight’s not over,” says Taylor, “then like, if I tell my doctor, what if, like, she tries to intervene?”
A young woman a few chairs away jumps in to agree with Taylor. Nijiah says she’d also worry about what her doctor might do.
“She’s going to try to get into the situation and try to make sure I’m safe, but possibly make things worse,” says Nijiah.
Matthew gives an example.
“When the doctor says, like, 'I have to bring it up to your parents,'” he says, looking around the room. “That’s why you can’t trust doctors.”
Unless, says Matthew, they promise not to tell.
“That will allow for trust to be built, and it will allow for people to be comfortable talking about any situation,” he says, and then asks the group: "Does anybody else agree?”
Chakaiya says she agrees as long as the doctor doesn’t call in a therapist.
“Sometimes I just like to keep myself to myself, like not trying to express it to other people,” she says.
There’s general agreement about answering two of the proposed questions: "Do you worry about your safety in school?" And, "Have you visited an emergency room lately?"
On school safety, Tamira says maybe things would improve “if I were to tell the doctor about it.”
Regarding emergency room visits, Aseani says her doctor should know if you’ve had a serious health problem.
“You could be like putting your life on the line not telling your doctor,” she says.
But Jamarri says people go to the ER because “they don’t want to tell their doctor.”
On the most probing questions — "Have you personally been affected by violence? "Have you ever felt you had to carry a weapon to feel safe?" "Do you have friends or family members involved in gangs?" — Altine-Gibson hits a wall of resistance and a flood of reasons for it.
“I would give 'em a hard skrrt,” meaning no chance of an answer, says Jahkhi.
“If you’re in a gang or something, if I say anything about that, then you’re a target,” he says.
Olivia is a definite no on all three questions about herself, friends or family members.
“That’s like my business and their business, not the doctor’s,” she says, “and, like, the doctor’s probably going to snitch so, no.”
“Alright,” says Altine-Gibson as the group fractures into many small debates, “so people are feeling a little suspicious as to why the doctors would ask you those questions. Or that somehow or another this information would get to someone that you don’t want it getting out to.”
And then, says Jordan, there’s the pain these questions dredge up.
“Let’s say if somebody very close to you died,” Jordan says. “If you say that in front of your doctor you’re going to probably have a nervous breakdown, which you probably don’t want to have in front of your doctor, 'cause it’s embarrassing.”
The room is quiet for a few seconds.
“That’s a fair assessment,” says Altine-Gibson.
For Tamira, a lot of these questions sound like something a social worker should ask, not a doctor or nurse.
“[Social workers are] there to listen to your problems and help you, give you advice and stuff,” she says. “While your doctor’s there for your health.”
Jordan has a question for Tamira: What if the person doesn’t have a social worker?
Maybe the doctor can refer them to one, Tamira says.
“So basically the doctor has to ask these questions to know that,” that the person needs a social worker, Jordan says.
Altine-Gibson wraps with a request for any last comments. Nijiah has this: Maybe instead of looking for signs of violence, doctors could ask, "'Do you need anything? Is there anything I can do, anything I can connect you to’ because, like, everybody needs something.”
The reluctance from many of these teens to answer questions about guns is no surprise to one gun rights leader in the medical field.
“To ask someone who’s at risk for these reasons whether they have access to firearms seems kind of ridiculous to me,” says Dr. Robert Young, executive editor at Doctors for Responsible Gun Ownership. "If they’re in this kind of situation they’re going to say 'no' anyway.”
Young says tracking school records, employment and home life experiences are all more effective ways to flag teens at risk for violent injuries or homicide than are questions from a doctor.
“The only times it’s even relevant to medical care is when a patient is showing indicators of dangerousness to themselves or others,” Young says. “But on a routine basis, gun ownership is just as legal as pool ownership and rope ownership and knife ownership and is really nobody’s business, least of all physicians.”
There is very little data on how many physicians ask their patients about access to guns or about whether doing so leads to fewer injuries or deaths. Dr. Eric Goralnick tracks the research as chairman of a Massachusetts Medical Society committee on preparedness. He says physician counseling can increase safer firearm storage but suggesting that patients get rid of their guns is less effective.
Goralnick is developing a gun safety screening pilot for the emergency room at Brigham and Women’s Hospital, where he works.
“This is one of the largest public health issues facing our nation right now,” says Goralnick, a former Navy officer. “Every firearm death is a preventable death, and we are in the business of preventing death and injury.”
Massachusetts General Hospital just launched a Center for Gun Violence Prevention and has begun training residents about how to discuss guns with patients. Boston Mayor Marty Walsh is lobbying for legislation that would have doctors ask all patients whether they have a firearm in their home.
Physicians who advocate for gun screening say patients are generally receptive. Doctors for Responsible Gun Ownership has guidance for patients who don’t want to respond to such questions and is building out a website where patients can connect with physicians who pledge not to ask about guns.
At the Bowdoin Street Health Center, Dr. Karanja is wrestling with the responses from his youth leaders. He worries about their mistrust, but he can’t promise blanket privacy. Doctors are required to report a patient in imminent danger. Karanja says he’s leaning toward more general questions about safety or injuries, some way to get at the impact of violence on his patients.
“They have to go around with this added burden about grief about people they have lost but also fear about whether they’ll be around tomorrow,” Karanja says. “It’s almost considered normal, which is terribly sad.”
Karanja says he isn’t sure about the timing of his project but he is aware it’s summer, the season when there’s often a spike in violence.
This segment aired on July 9, 2019.
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