“There are things we can do now to change this,” Dr. Kathy Barnhouse, a professor of family medicine at the University of North Carolina School of Medicine and co-author of the study, said in a press release. “We discovered that the great majority of physicians feel that assessments for concealed weapons permits should best be done by providers specifically trained in making such assessments, presumably with standards to make assessments about mental and physical competence.”

Dr. Adam Goldstein, a study co-author and professor in the department of family medicine at UNC, thinks the problem lies with a lack of uniform standards and public policies across states to determine what is dangerous enough to justify denying a permit.

“Doctors are qualified to do this, but they need guidance,” Goldstein said in a telephone interview. “The physician that best knows the patient is the best type of physician to do these assessments. In most cases, that would be the primary care physician. Doctors who have special training, who may not be the primary care physicians, may also be qualified to do it. The type of questions being asked involve physical and mental capacities. The problem is there are no criteria for assessing them.”

When law enforcement agencies ask doctors to attest to an applicant’s mental or physical fitness to carry a concealed gun, they may send a minimal form to the doctor, and sometimes a request for more detailed medical records. The problem is, Goldstein says, the current forms are not comprehensive enough for this type of assessment. The Department of Transportation has more detailed regulations about who can conduct “transportation physicals” for commercial motor vehicle licenses.

“When you do a transportation physical, there are forms that ask about cardiac, respiratory, emotional, neurological, and psychiatric conditions," Goldstein explained. "If, for instance, one has neuropathy, dementia, or a cardiac condition, you would want to know how severe it is. We could develop such forms [for concealed weapons permits] relatively quickly and educate providers about what the expectations are.”

In the absence of a clear protocol, doctors may have different opinions on what constitutes mental and physical competence to carry a concealed gun. In a 2013 article in The New England Journal of Medicine, Goldstein and co-authors wrote:

Reasonable physicians might disagree about whether patients with severe Parkinson's disease, prior strokes, atrial fibrillation, seizures, or chronic pain are physically competent to use a weapon safely, as well as about whether people who have a history of depression, substance or alcohol abuse, anxiety, or insomnia or who are taking psychotropic medications are mentally competent to do so. Guidance is needed regarding the need and protocols for collection of urine toxicology or blood alcohol reports to rule out drug or alcohol use before signing off on permits.

The North Carolina survey also showed that doctors are concerned about the potential ethical consequences participation in this assessment might have for the doctor-patient relationship. While the Affordable Care Act forbids the collection and recording of data about patients’ gun ownership, the Obama administration has made it clear that health laws do not prevent physicians from disclosing necessary information about a patient to law enforcement, family members or other people when the patient is deemed to present a serious danger to himself or others. But the American Psychiatric Association has cautioned against laws requiring doctors to talk to law enforcement about patients who may appear to pose a threat to themselves or others.