‘A lot of good we can do together’

Dr. Emmy Betz on working to prevent firearm injury and death with gun shop owners and instructors

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Courtesy Dr. Emmy Betz

Dr. Emmy Betz can’t overemphasize the impact the lack of funding for firearm violence injury prevention research has had. A decade ago, when she first started her research career, there wasn’t any dedicated funding. At the time her mentors told her, “Listen, you probably don’t want to do that. There’s no money. Politically, it could be suicide for your career. You should just focus on something else,” Betz recalls.

Even the National Institutes of Health (NIH) told her researching firearms could be part of a larger project on injury prevention but it couldn’t be the focus and “firearms” couldn’t be in the title of a grant, she says. Then the Sandy Hook Elementary School shooting happened, President Obama changed NIH’s policy, and since, Betz has worked on several grant projects collaborating with the firearms community, using their perspectives and views to frame her research on firearm injury and violence prevention.

Still, she says, much more funding and research is needed. 

“This new infusion is important, but we have a lot of catch-up work to do,” she says. “I get questions all the time about like, why does this happen? Or what is the meaning of this? And we just don’t know.”

Betz is an emergency physician and researcher at the University of Colorado School of Medicine, the director of the school’s Firearm Injury Prevention Initiative and cofounder of the Colorado Firearm Safety Coalition, which gathers firearm retailers and instructors, public health and medical professionals, and members of the public with the goal of preventing firearm suicide.

While high profile mass shootings, like the one in Boulder on March 22, tend to take the media spotlight, in 2020 there were approximately five firearm deaths every hour in the United States. Even more staggering, suicides make up about 60% of gun deaths in the country, and in Colorado it’s even higher: suicides account for 76% of the state’s firearm deaths. 

“They’re not more important, but they shouldn’t be less important either,” says Betz, who has friends and family who have struggled with suicidal thoughts or died by suicide. “I think part of the reason I really got into firearms suicide prevention as my research area is because I felt like there was a lot more that we could be doing.”

Boulder Weekly recently caught up with Betz to talk about her work, her focus on community solutions to firearm injury and violence, and how to find common ground on the polarizing issue of guns in America. 

This interview has been edited for length and clarity. It reflects her views, not those of her employers.

Boulder Weekly (BW): As an emergency room doctor, what’s your experience with firearm violence? 

Emmy Betz (EB): Thankfully, Colorado has less interpersonal violence than some places. But we certainly see a fair amount of interpersonal violence, especially among youth, often among communities of color. And we certainly see a lot of cases of domestic violence too. And I think we have a lot of work to do in terms of how do we prevent those injuries as well as for victims: How do we support them afterwards and try to break the cycle of violence? 

I would say though for me, in some ways, when I think about my role as an ER doctor, sometimes it’s almost about what’s missing, which is the suicide cases that don’t make it to the ER. We occasionally will see someone who has shot themselves and it’s usually not a survivable injury. But we don’t see that that often because usually people are dying at home. And for me as a clinician, it’s thinking about how do we prevent these?

I think the other piece for me that has been really important and what led me to find this collaborative approach is, as a clinician, I’m trained to talk to people in a way that is respectful — to meet them where they’re at, encourage them and educate them as best I can about health behaviors, but also not tell them what to do. And we’re really good at that for a lot of things: When it comes to sexual practices, alcohol use or injection drug use or other activities that might come with risks, we’re really good at asking questions and counseling people in a way that is non-judgmental. And I felt like I didn’t know how to do that when it came to guns. 

No one had ever trained me how to talk to a patient who’s suicidal about locking up guns at home. I also feel like no one had ever really trained me about how to intervene with a youth who’s been shot in the foot and is going to be OK, but what do we do now? How do we keep the cycle from repeating itself? And so I think it was my perspective as a clinician, being at the bedside and thinking, what words do I use? Like, how do I talk about this? That really helped me get into this space of finding ways to work together.

BW: Is there any reason why doctors shouldn’t talk to patients about guns and if not, how do you do that?

EB: There’s no current federal or state law that prohibits doctors or health care providers from talking about guns. There was that issue in Florida but it’s gone. (Editor’s note: A 2011 law in the state prevented medical professionals from asking whether or not their patients owned guns, supported by the NRA, which argued it was necessary to protect Second Amendment rights. A federal appeals court ruled the practice unconstitutional in 2017, as it violated doctors’ free speech rights in providing medical advice to patients.) 

I do think it’s a really important role for physicians and other health care providers when the context is right. I’m not an advocate for universal screening. Asking adults if they have a gun when they’re in the ER for an ankle sprain, there’s no reason to do that. And I understand why patients might wonder what the data is being used for. But I think there are a couple of situations where it does really matter.

Somebody who’s suicidal or at suicide risk, we know that it matters there. Same with domestic violence, because if a gun is in the picture, it significantly increases the risk of death to the victim. With interpersonal violence the approach is different. It’s not about, “Just go home and lock up your gun.” It’s about how do we engage you in a program and get at the root causes of violence. We also think about cognitive impairments or dementia. I think it makes sense that someone who’s cognitively not as able to process and think about the implications of actions probably shouldn’t have access to a gun. People with significant substance use disorders also are at higher risk because they’re impaired. And then little kids we think about as well. 

The specific approaches and recommendations vary a bit group to group, but the general message is to approach the conversation respectfully. So it’s not about trying to change someone’s identity. It’s not about arguing about if they should or shouldn’t own guns. It’s about assessing if there are specific risks based on how guns are stored, and then being a resource to help brainstorm how to reduce those risks — really focusing on giving the person the agency, the independence to make those decisions and then making clear that it’s about voluntary actions. It’s not about me telling you what to do. It’s not about the government telling you what to do. It’s about you understanding how to make your home as safe as possible, because at the end of the day, we all want the same thing: Nobody wants their families or friends to be dying from or injured by guns.

BW: Where does cultural competence come into play? Do doctors, especially those who aren’t gunowners, know how to talk about guns?

EB: For clinicians, I think cultural competence is about understanding and respecting the gun culture of the patient and by gun culture, I mean there are lots of different gun cultures actually. 

Many people own guns for self-protection. In that context, cultural competence would mean recognizing that that person probably wants access to a loaded handgun in their home, for example, so they’re probably not going to be interested in using a cable lock or locking device that requires them to unload the gun, because then the gun is not meeting its purpose. But a rapid access lockbox they might be interested in. 

Other people in broad groups within gun culture includes people who own guns more for Second Amendment beliefs and sort of this almost ideal of it. Some people who own guns for hunting once a year, they’re going to store guns very differently than those who have them for protection. Certainly military or veteran culture have important context, too. And so for clinicians, it’s about understanding reasons for ownership, what guns mean to the person, and what kinds of more secure storage they’re willing to talk about. Because at the end of the day, it’s about reducing injuries and it’s about reducing risk of death. It’s not about changing that culture.

We already think about cultural competence, for example, in the context of, say, religious preferences. So there are some people who follow religions that prevent blood transfusions. So as a health care provider, I would never force someone to get a blood transfusion. If it was against their religious beliefs, I would try to talk to them and make sure they knew my view on the risks and benefits, but ultimately it’s being respectful of their cultural background and why they’re making that decision.

BW: Why is collaboration, as well as education and scientific research, part of the mission of the Firearm Injury Prevention Initiative?

EB: The initiative exists to try to support and build bridges between researchers and community programs. It’s also to support researchers, public health practitioners and clinicians with this culturally competent lens — to try to build connections to the firearms community, to other communities with so-called lived experience. So in the suicide realm, it’s critically important to engage people who’ve been suicidal themselves, who’ve lost loved ones, the same way when it comes to community violence, it’s critically important to be engaging the at-risk communities in this sort of intervention. 

I talk a lot about how policy is not the only fix. I do think there’s a role for legislation and for various policies. But there’s so much we need to do in the space of education, of community outreach, of programming and those kinds of things. You can’t do those without incorporating the views of the people you’re trying to reach. You just can’t. It would be like if you were trying to do any kind of education outreach with the LGBTQ community, and you went in with homophobic views. We wouldn’t do this in any other area. So if we want to be educating the firearm-owning community about why safer storage or reduced access can lower the risk of suicide, which we know is true, we can’t do that without engaging them. Shame on us in public health for not realizing this sooner. We’re not going to agree on everything, but of course we need to be working together.

BW: That brings us to your work with the Firearm Safety Coalition, which you cofounded in 2015. Tell us about that. 

EB: After I wrote a journal article in JAMA on the concept of cultural competence when it came to firearm safety counseling, I got an email from Michael Victoroff, a firearms instructor and physician in Colorado who read it. 

We had this sort of awkward first conversation and then I ended up taking a firearm safety class with him and together, through his connections in the firearms community and my connections in public health, we formed the coalition. And it’s loose, it’s not a coalition of organizations. It’s just individuals who come. I think its biggest impact has been being a space where we can learn from each other and where we can discuss tough topics in a way that is respectful and oriented towards this common goal of none of us wanting more suicides to happen. And it brings together people in a way that I had not gotten to be a part of before and it’s just been the best part of my career for sure.

BW: What have you learned most from gun shop owners and firearm instructors? 

EB: When I started this work, it did feel like the other side to me because I’m not a gun owner myself. So when I was talking with patients who own firearms, I didn’t know what to say. It felt really awkward. But I think I have stopped viewing them as the other side. Probably the most important thing for me was recognizing my own biases and being able to break those down. 

And I think recognizing that for many gun owners, their reasons for owning firearms and the way they store them, they’re based on deeply held either beliefs or perspectives on safety, or response to fear. And these are behaviors or beliefs that are really hard to change. 

And so it’s not just about throwing numbers at people. I think sometimes there’s this implication that if we just tell people more numbers, that they’ll realize they were so wrong in owning guns and they’ll give them all up. And it doesn’t make any sense, because all of us have fears and respond to fear in different ways. And so I think it has really helped me think about the problem of firearm injuries and deaths from a different viewpoint — how do we use what’s called a harm reduction model of trying to reduce the risk of harm without requiring changes to underlying behaviors.

BW: As a researcher, is there any sort of quantifiable outcome of your coalition work?

EB: I wish there was. We did a firearm counseling training for physicians a couple of years ago with a very small group. We did some presentations, let physicians learn about guns and then they had the opportunity to shoot if they wanted to — I don’t think clinicians actually need to go shoot to learn how to talk about this. In that very small study, participants had increased knowledge and comfort afterwards. But with the coalition itself, there’s not really anything we can measure. Although it certainly has, in my opinion, led to new projects, new ideas and then those research projects themselves eventually may have outcomes. But you can imagine these are things that are really hard to study because it’s like, how many times did you see a billboard or a poster? And so my take on it is at the end of the day, it’s at least fostering a conversation that wasn’t happening before. And I think that’s a huge impact even if I can’t put a number on it.

BW: With mass shootings, like the one in Boulder, the gun debate tends to heat up and there’s a lot of focus on legislative solutions, but why do you think it’s important to focus on community solutions? 

EB:  I do sometimes get involved in policy, but my research background is not in policy. For me, my research comes from my role as a clinician, and I’ve been more interested in one-on-one or community interventions. As I have been doing this work, I have felt sometimes I can have a bigger impact by staying a little bit away from policy, if that makes sense. So I do work writing and speaking, talking about evidence and talking about science. But I generally don’t get involved in lobbying or direct advocacy because I feel like sometimes the messages get twisted a lot and I’m working hard to build trust and build these relationships that are really important. 

BW: How do you find common ground to address these issues?

EB: We do have a lot of common ground here. None of us wants to be losing friends or family, gun owners don’t want these things to be happening. We might disagree on how to get there, but we have a common goal. And I think if we keep that in focus, I think it can really help. If we really want to make progress, we have to stop and listen to each other. Clearly this strategy of just yelling at each other is not working. And there’s a lot of good that I think we can do together.