Extreme Risk Protection Orders, or “red flag” laws, are a state policy tool designed to temporarily remove firearms from individuals who are behaving in a manner dangerous to themselves or to others. As state laws, they vary in their design and implementation, including who is able to petition to have firearms removed. In some states with red flag laws, physicians, pediatricians, and other clinicians are enabled by law to fill this role. On this episode of Policy Outsider, we explore why clinicians are well-suited to be ERPO petitioners and their challenges and concerns with the laws as currently constructed.
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Joel Tirado 00:10
welcome to policy outsider presented by the Rockefeller Institute of Government. I’m Joel Tirado. Extreme risk protection orders or red flag laws are a state policy tool designed to temporarily remove firearms from individuals who are behaving in a manner dangerous to themselves or to others. As state laws, they vary in their design and implementation, including who is able to petition to have firearms removed. In some states with red flag laws, physicians, pediatricians and other clinicians are enabled by law to fill this role on this episode of policy outsider, we explore why clinicians are well suited to be erpo petitioners and their challenges and concerns with the laws as currently constructed. Our guests are Shannon Frattaroli, a professor at the Johns Hopkins Bloomberg School of Public Health, and Nina Agrawal, a pediatrician and a Richard P Nathan Public Policy Fellow at the Rockefeller Institute.
Joel Tirado 01:03
right, Nina and Shannon, thanks for joining me on the show today. It’s good to be here. Thank you for having us. Thanks for having us real quick before we jump into our conversation about erpo, extreme risk protection orders. Could you share a little bit about yourselves, you know, especially as it relates to your experience with red flag laws, and just based on my screen here, Shannon, you’re on top. So why don’t you just go ahead first
Shannon Frattaroli 01:51
Sure. Happy to Hello everybody. My name is Shannon Frattaroli, and I’m a professor at the Johns Hopkins Bloomberg School of Public Health. I’m in the Department of Health Policy and Management and affiliated with a center there called the Center for gun violence solutions. So I’ve been working on gun policy, gun gun laws, as a strategy for reducing the tremendous toll that violence takes on this country for decades at this point and have been very enthusiastic about the potential of extreme risk protection order laws or red flag laws. You’ll probably hear them us refer to all of those references throughout the course of this conversation, I’ve been working on this issue for about 10 years now, so this is a policy initiative that, from my perspective, holds great promise. And very happy to be here to talk with you both about this.
Joel Tirado 02:51
That’s great. Thank you, and we’re excited to have you here and Nina a little bit on your background,
Nina Agrawal 02:56
sure. So my name is Nina Agrawal. I’m a pediatrician. I’m also a board certified child abuse pediatrician, and I’ve been practicing in New York City, and I started getting involved in gun violence prevention advocacy after the shooting at Sandy Hook and then over time, on a statewide basis and a local basis in educating myself and other pediatricians on policies and what does that look like in practice for our patients, especially in New York City. So thank you so much. Really excited to speak with both of you today.
Joel Tirado 03:44
Thank you. Nina, yeah. So you know there are a lot of good resources. I know Shannon at Johns Hopkins. There’s the pretty recently awarded, I’m going to get the name wrong, but basically the Center for erpos, right? That is this kind of like National Resource Center. So there’s a lot of good resources that explain to folks what red flag laws are. So I don’t want to, you know, take too much time going over that, but I do think that a sort of brief overview of what these laws do, and who is, you know, who uses these laws and who they affect. You know, kind of the process, just a just a brief overview,
Shannon Frattaroli 04:28
sure. Well, I can jump in here. This is Shannon. So extreme risk protection order laws are a relatively new tool that on the policy landscape, and what they do is provide a mechanism to temporarily dispossess people who are behaving dangerously and at risk of violence from purchasing and possessing guns. I know that that’s a mouthful, but the basic idea is that when we see someone who’s. In a way that suggests they’re on a trajectory of violence. Herbals provide a way to intervene with the concrete action temporarily removing guns, and both take away that Lethal Weapon and kind of clear a safer path to help deal with the crisis that the person is in now erpos. What we’ve seen across the country is that erpos are being used to address people who are at risk of self harm, so suicide. We’re also seeing her posts being used with regard to interpersonal violence and domestic violence, and we’re seeing instances of erpo use when there are threats of multiple or mass shootings. So they’re a tool that’s really being applied to a wide range of gun violence risks. And again, it’s something that is relatively new on the gun violence prevention policy landscape. 21 states and the District of Columbia now have access to this tool.
Joel Tirado 06:08
And so you know, for the purposes of our conversation here, where we’re going to be talking about physicians and clinicians, as you You pointed you both pointed out to me in a little conversation that we had before we’re speaking now, who petitions to have these, these firearms taken away? How does you know, sort of briefly, how does that process work?
Shannon Frattaroli 06:33
Yeah, it’s a great question, and it’s a question that varies depending on the state that you’re in. So in all of those 21 states with erpo laws and DC law enforcement can petition. In most states, family members partners can also petition. And in a growing number of states, six and the District of Columbia, clinicians, including physicians, can also petition. A handful of states have other petitioners, like school administrators, co workers, but by and large, this is a tool that is invites law enforcement, invites family and partners, and again, increasingly, we’re seeing physicians and clinicians also being authorized to initiate the erpo process.
Joel Tirado 07:27
And why do you think that that set of professions is being brought in as petitioners? What makes them well suited for for that role?
Shannon Frattaroli 07:41
Yeah, well, I can say that. So erpo is about interrupting a trajectory of violence, and when we think about who in society kind of has a window into that trajectory, you know, certainly clinicians, certainly physicians, are often part of the people who are, who we turn to when we’re in crisis, right? So when someone is, you know, again, in crisis and might be experiencing thoughts of suicidality. You know, a physician, a clinician, is a person who we often turn to when, when person, a person is engaging in violent behavior. Again, clinical people are the professionals who we turn to, so I think it makes great sense that we’re looking to our clinical partners to help with both our problems around violence risk and also making sure that they’re equipped with the tools to intervene and prevent violence from escalating. Were happening?
Joel Tirado 08:48
Yeah. So Nina, when did erpos Kind of get on your radar as as a tool so as a pediatrician, when did you become aware that this was a policy that was being implemented in which you could play some part.
Nina Agrawal 09:09
Yeah? Well, great question. Yeah. I been in the advocacy world or circuit for several years now, and I happen to be the the governor signing of strengthening legislation in New York State for gun violence prevention, and this is after the volde shooting, and it was after the top supermarket shooting in New York and At that signing, I learned that clinicians would have direct access to erpo as petitioners. And then I started thinking, oh, what does this mean, and how as I, as a clinician, can use that? And so that’s when I started, when it when it hit home for me in terms of being a pediatric.
Joel Tirado 10:00
Shouldn’t, have you spoken with and have you gone through that process yourself? Is that, is that a HIPAA law? I don’t want to, I don’t want to, you know, go down any road. But are you familiar with the process in that kind of, like, intimate, personal way?
Nina Agrawal 10:17
Yeah, as far as being a pediatrician, you know, as you all know, we have a youth mental health crisis that that surge during the pandemic, it had been turning upwards, but then during the pandemic, we it just, we’re just seeing so many youth with suicidal thoughts. So I’d have to say, like on a weekly basis, I have a an adolescent with suicidal thoughts, and then I go through, you know, suicidal thoughts, suicidal plan and any access to to any shark, objects or weapons, anything that they could use to harm themselves. And you know, that’s been something we’ve always done, but now it’s we realize it’s really important that we ask about access to firearms, in addition to, you know, a knife perhaps, in the home. And so that is something that I now routinely ask about. And then on top of that, now I have the erpo as a tool to make sure that if there is a firearm that it can be removed, that can possibly be removed. So as Shannon was saying, it’s it’s a tool that we can use to help keep children safe from harm, from themselves and others. And Nina, you’ve, you’ve done some research here. I believe you did a, you did a survey right of, of, was it your fellow pediatricians in the state? Or could you tell us a little bit about some of the the research that you’ve done? Sure. So you know, as I was saying before, when we have policies, what does that look like in practice? And that’s been an area of interest in me. How do we we have a great tool, but how can we make sure that doctors use it, and specifically pediatricians? So last fall, I linked up with pediatricians across the state, in upstate New York and downstate, and we surveyed nearly 200 pediatricians that were part of the American Academy of Pediatrics in New York. And we looked at barriers and facilitators, and we use some of the questions that that Shannon has used for clinicians and and then further looked at it, I guess, and for for for pediatricians, and what would the various facilitators be specifically for pediatricians? So we got some interesting results, and we’ll be presenting that at a couple upcoming conferences.
Joel Tirado 12:56
Great. Well, I don’t want to steal the thunder from the from the upcoming conferences, but one of the things that you know, as you’re saying that strikes me as interesting, is, what are some of the differences between, say, like a general practitioner, for adults who might be learning about this tool, and pediatricians who are learning about it that they might the differences in situations that they might encounter that would provide sort of different challenges for both of them as potential erpo petitioners.
Nina Agrawal 13:30
Yeah, well, one is, as a pediatrician, our goal is to make sure that child is safe and gets the help that they might need and and that the family also gets the support and help that they might need. So I think that would be perhaps unique to pediatricians, in that once we would, you know, file for an erpa, I want to know what happens after that. You know, is it going to be harmful? Is it going to be helpful to that child. And the other is that we may see a child who’s risk, at risk of harm by a parent, but that parent, and that has happened to me in intimate partner violence situation, but the way, or both legislation is, is that as a physician, I can file an orpo against only a patient. It can’t be the parent of a patient. So that is sort of a nuance that, you know, we’d like to understand and we’re working through, and
Joel Tirado 14:35
that’s interesting. And Shannon, so you Shannon, you’re not a clinician, but you’ve had, you’ve done these surveys and had many, I think, qualitative conversations you mentioned, with folks who are clinicians. So what are some of the challenges that these folks highlight with with their use of the erpo law? I.
Shannon Frattaroli 15:00
Yeah, thanks for that question. And maybe I’ll back up a minute and say that the reason that I’ve done a bit of work around clinicians as or both petitioners is because Maryland, when we passed our law back in 2018 we were the first state to include clinicians as petitioners. I’ll also note that I know that you have a New York friendly audience, and that, as Nina was saying, New York also has clinicians as authorized petitioners. So New York, Maryland, Connecticut. Oh, let’s see if I can name them all, Hawaii, DC, and there’s one more I knew I shouldn’t have gone down that path. Oh, Michigan,
Joel Tirado 15:42
well done.
Shannon Frattaroli 15:43
Yeah. Thank you. So this was an innovation in the law that was of great interest to me. And while I’m at a school of public health, I work with a lot of physicians and other types of care providers. And so we wanted to understand how this was going to land with the clinical community, what kind of barriers and facilitators and what we could really do to make sure that implementation for clinical providers was was realistic, and if there were challenges to be addressed, that we documented those and were solution oriented, and what we found, you probably don’t need to be a physician to to sort of guess what we found. But the physicians that we surveyed said, overwhelmingly, you know, well, one we don’t know what this is, but when we told them what an erpo is, they said, Wow, that sounds like a good, good idea. And when we asked them, so what does this mean for your clinical practice? How how many patients, or how frequently would you imagine using an erpo Just kind of thinking back across different time points? And you know, overwhelmingly, we saw large majorities of physicians who said they would use it multiple times during the any given year, many who said multiple times during a month and even multiple times during a week. Emergency medicine physicians in particular were guessing that they would be or predicting that they would be high utilizers. But when we got into kind of the nuts and bolts of what this looked like. And said, Okay, this is a tool that you could imagine using talk to us about what some of your concerns are. Overwhelmingly, what people said was, you know, wow, when I think about my clinical schedule, I don’t have the time to add another layer of administration onto what I already do, to fill out the paperwork to go to court, provide that testimony, that’s just not in the cards when I look at what I do on a day to day basis as a physician.
Shannon Frattaroli 17:55
And so we went a little bit further and said, Well, what kind of services or how could we help some of the challenges that you face as a potential Petitioner for erpos, and one of the options that we asked about was if someone who was a designated, what we call an erpo navigator, who could be called upon to come on to their teams when someone might be a good candidate for an erpo, might benefit from from an erpo, and if the team decides that yes, this patient that we’re we have in front of us does qualify, and we think this would be a good addition to their clinical care plan that erpo navigator would step in and handle the paperwork, handle the court testimony, and really just take that additional administrative burden off of the in this case, physicians plate and so we’re we’ve been working For the past year here in Baltimore City to advance that model, and we have a community partner, the Baltimore crisis response team, who is providing access to some of their trained, licensed clinical social workers who are trained in erpo processes to be available to physicians at our hospital when, again, they identify a patient who might benefit from an erpo, they come in do their own assessment and take over that piece of the care plan.
Shannon Frattaroli 19:37
So it was a long winded answer, but I’m really excited about, you know, both the the potential of this tool in clinical hands, acknowledge the barriers that clinicians face, and excited about the potential to address the most significant barrier which we hear about, which is time.
Joel Tirado 19:59
And you know, as I. Is that sort of, was that kind of corroborated in your survey of pediatricians, that the administrative burden is a major limiting factor, and also, you know, a lack of awareness about the law and how it works. Are those some of the major things that you that you found?
Nina Agrawal 20:19
Yeah, for sure, undoubtedly. You know, it was lack of time, lack of training. They were interested in hearing about the law. They wanted legal consultation. You know, hey, is this something that would be eligible for an erpo, a filing coordinator? So, yeah, all of the the things that Shannon mentioned, they also were concerned, though, about liability protection. You know, you know, if they were to file, could they be sued? And they were also concerned about their personal safety. I do want to make a mention, I think, you know, one of the things that we look at is translation of policy to practice and different people practice in different settings. So a hospital setting might be different from, you know, private practice, like a solo practitioner who and that’s sort of where I found myself in not having legal counsel or social worker or team to support me in helping file in our bow.
Joel Tirado 21:24
No, that’s good. Yeah, that’s a good point, right? That kind of tees up. My next question is, you know, what additional supports do clinicians of various types, you know, in various settings, what do they need to be most effective.
Nina Agrawal 21:43
My wish list, one is we have a tool. I think, you know, we’re starting at a good place, and we have Hopkins, you know, the Center for gun violence solutions, as a resource. And that is a really great start, and there is federal support for that. So I think we’re starting from a good place as far as training and additional resources trying to make this work. I think one of the challenges that we have is that, you know, we’re learning is that it variescounty by county in New York, and I would imagine I’ll let China and speak to how it’s happening in other states. But that is, that is, that is a challenge. You know, what? If your patient resides in another county, law enforcement in one county might take your concern directly, move the ball forward for you. Another County, they may not have those law enforcement resources and be able to do that. So you know, the how it’s happening on the ground varies, and I think we need to centralize it. And as a child abuse pediatrician, I actually really appreciate our child abuse mandated reporting system where there’s a central hotline. We all call that hotline, we tell the hotline our concerns, and there’s, you know, a wraparound approach to that concern. And then, you know, I might be involved after that, but I have passed my concern on to the authorities who will, who will move the ball forward in the best interest of the patient and the family. I would hope,
Joel Tirado 23:22
Okay, interesting. So, so you would imagine a similar kind of model for erpos in your Nina Agrawal wish list.
Nina Agrawal 23:35
Yes, yes. I would love to see that happen. And you know, perhaps with time it I actually am hopeful it will happen.
Joel Tirado 23:45
It sounds not too dissimilar to what you were describing Shannon with the with the navigators. I mean, that’s obviously a little bit little bit different. But the idea of being able to to then pass this information that you’ve obtained from your position as a clinician, along to other folks who are experienced in the law and can take over that that portion of things, sort of splitting up the responsibility A little bit.
Shannon Frattaroli 24:18
Yeah, exactly, you know, recognizing that there’s, there’s benefit right, in having professionals specialize in this. You know, there’s efficiencies with that. There’s greater, you know, attention to accuracy with regard to how the tool is used. And perhaps most importantly, it makes it viable for treating clinicians, right? Because, again, just expecting clinicians physicians to add one more thing onto their plate is just a recipe for what. Our implementation. So from our perspective, the navigator is one approach that we’re trying. We’re excited about it, and we’re in the early phases of this pilot, but look forward to sharing what we learned from this experience down the road.
Joel Tirado 25:17
Yeah, we’ll look forward to checking back in on that. Do we have data on who are petitioners? So I know I didn’t cue that question up to you beforehand, so, but just let me know what, what, what you know about, what we know of who petitions to have these firearms removed?
Shannon Frattaroli 25:40
Yeah, so it varies by state, but given the focus of our conversation today, I’ll say that, as best we can tell, this isn’t a tool that’s you know, clinicians are not among the petitioners. So the data that I have in Maryland points to a number that’s less than 1% of the petitions that are filed here are filed by clinicians. There’s a little bit, there’s a little bit of a perhaps misrepresentation in those numbers. And that we do know that, you know, I talked to many physicians who will say, Oh, well, we’ll bring this conversation into, you know, the clinical environment. I’ll talk with my patients and their families about this option when someone is in crisis. And so I’ve had patients spouses who have filed for an erpo as a result of the conversation that I’ve had with them. Or I contact law enforcement when I want to move forward with one of these things. So it’s not, you know, the less than 1% number sort of hides some clinician involvement, but by no means would I guess that it’s above 5% you know, of what we’re seeing in Maryland, most of the petitions across the country are filed by law enforcement, and in most places, it’s an overwhelming majority that are filed by law enforcement. There are a couple of states, Maryland being one of them, Colorado, the other where there’s a significant proportion, you know, 40 some percent, of petitions that are filed by family members, by partners.
Nina Agrawal 27:53
I just want to add to that. What Shannon was saying is that, I think it’s a really good point, is that the vision role as petitioner is one role. They can also be educators. They can counsel patients or, you know, spouses or other family members, parents on you know, this is a tool that you have if you’re concerned about a family member, your child, and you can be the petitioner, and I’m going to help direct you, right? I’m going to help navigate you. Help you navigate that that process, and the other is a communicator, and that you have a concern, and you communicate those concerns to to law enforcement, who can, who can then be the petitioner. So I think those numbers tell us, you know, that physicians are not acting as petitioners, necessarily, but there is interest. And what are the different ways that physicians can better access ergo, for their patients? Right? Right?
Shannon Frattaroli 28:55
Yeah, and just maybe, Joel, if you don’t mind, I’ll just amplify Nina’s point to say that, you know, oftentimes, when I’m talking with physicians outside of those six states in DC, they said, Oh, well, this all sounds great, but, you know, I’m not allowed to petition here. And you know, just to really emphasize exactly what Nina just said, I mean it, you don’t have to be able to be named as a petitioner, as a physician or a clinician in a state with an ERP law in order to have a really big impact on how that tool is used in your communities, in your clinical practice.
Nina Agrawal 29:34
Yeah, yeah, that’s a great point. You know, we’re nearing the end of the conversation, and I want to borrow a method from my journalist friends and ask you both the open ended question of, you know, what should we have talked about here in this conversation that that didn’t come up, because for me, it’s urgency of now, we have a tool. We have a lot.Law. We need to use it. We don’t need an act of Congress at this point. We need people to come together, you know, like we are doing, and more stakeholders to make this happen. We don’t want to wait until something bad happens. And I’m like, oh, you know, why don’t we use the Red Flag Law? So I would have to say, you know, let’s do it. Let’s make it happen. Yeah,
Shannon Frattaroli 30:29
yeah. Definitely echo that, yeah, that there. There is an urgency. We have a crisis in in this country with regard to gun violence, and this is one strategy for addressing it. I think one thing that that oftentimes comes up with people, when I have conversations around or Bo is,oh, you know, this is a, this is a heavy lift to ask of anyone to say, you know, to talk about temporarily removing guns from someone that’s just not the kind of thing that you do in our country. And, you know, I like to point out that, you know, it’s easy to return a gun, right, but you can’t return a life, and that’s really what we’re talking about when we talk about people in crisis having ready access to guns. So as Nina said, Let’s not wait. Let’s use this tool where we see people are in crisis and at risk of harm. Let’s let’s clear a pathway for safe treatment, for safe intervention, and help them to live long and full lives.
Nina Agrawal 31:45
Yeah, just want to add to that is that, you know, I think it can be confusing for the public, even for practitioners. There’s so many, I guess, opinions out there and options out there. And I, you know, and I think this is so important right now, what is a public health approach? And you know, one is that this is an evidence informed tool. It’s backed by science. It’s backed by data. It’s not my opinion, it’s not a theory. It actually has worked. You know, do we need to expand upon it? Yes, but there is data to back it up. And then the other is, what can I do? You know, there are a lot of things that you know, that I may not have control over, you know, on a federal level, but there’s something I can do in my practice, and I can do it tomorrow. So I try and think about what’s what’s practical as well.
Joel Tirado 32:37
I thanks again to Shannon frattaroli and Nina Agrawal for joining us on the show to discuss the role of clinicians in reducing gun violence through red flag laws. If you liked this episode, please rate, subscribe and share it will help others find the podcast and help us deliver the latest in Public Policy Research. All of our episodes are available for free wherever you stream your podcasts and transcripts are available on our website. I’m Joel Tirado Until next time,
Joel Tirado 33:22
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