Emergency Physician Survey on Firearm Injury Prevention

Where Can We Improve?

David A. Farcy, MD; Nicole Doria, MD; Lisa Moreno-Walton, MD, MS, MSCR; Hannah Gordon, MD, MPH; Jesus Sánchez, PhD; Luigi X. Cubeddu, MD, PhD; Megan L. Ranney, MD, MPH

Disclosures

Western J Emerg Med. 2021;22(2):257-265. 

In This Article

Results

A total of 1901 respondents completed surveys, of whom 62.3% self-identified as men, 79.8% as White, and 64.3% as attending physicians (Table 1). All regions of the country were represented, with the highest proportion of responses (32.0%) from the Northeast. Three quarters (75.3%) of respondents identified their location of current practice or residency training site as a large city or a suburb near a large city. Most (86.1%) of the respondents were civilians without any military experience. Almost half (42.9%) reported having at least one firearm at home, of whom 84.8% personally owned the firearms (Table 1). More than half of participants (56.0%) had some prior training on firearm safety for personal use, more than half (57.1%) strongly agreed or agreed that personal ownership of firearms by private individuals in the US should be a constitutional right, and almost half (45.1%) strongly agreed or agreed that personal ownership of firearms protects personal liberty. Demographic differences were observed in who reported having a gun at home, with male (49.3%) and White (45.1%) respondents being more likely than women (30.3%), Hispanic (34.2%), and Black (22.8%) respondents, while rural (58.7%) and small town (51.9%) respondents reported being more likely to have a gun at home than respondents in large cities (38%) or suburbs (44.5%). Of respondents who considered gun ownership a constitutional right and a personal liberty, 81.0% and 85.9% reported having a gun at home. (Table 1).

Regarding barriers to asking at-risk patients about firearms, most (51.4%) reported "no barriers to, or felt comfortable with, asking patients about firearm access" (Figure 1). Yet almost half (47.7%) reported lack of knowledge (e.g., "I don't know what to do with the information"); more than half (55.8%) reported attitudinal barriers (e.g., "I don't think it makes a difference"); and one-fifth (21.3%) reported negative attitudes and normative beliefs (e.g., "Asking is someone else's responsibility, not mine") about screening (Figure 1).

Figure 1.

Participants were asked which of these are significant knowledge, attitudinal, and norm-related barriers to personally asking patients about firearm access. (Total n = 1,701.)

Respondents had a wide variety of beliefs about counseling on firearm injury prevention. Only a quarter (25.7%) of respondents "strongly agreed" or "agreed" that patients would change how they store their firearms if physicians educated patients on firearm injury prevention. Almost half (46.1%) said that they personally had the training necessary to educate/counsel patients on firearm injury prevention. Nonetheless, nearly three-quarters (71.0%) wanted additional training in procedures to follow for patients at risk, and only a quarter (24.8%) "strongly agreed" or "agreed" that EPs in general are knowledgeable about firearm injury prevention (Figure 2).

Figure 2.

Participants agreement with the statements about training in firearm injury prevention (on a scale from strongly agree to strongly disagree).
EM, emergency medicine.

Self-reported frequency of asking patients about firearm access was dependent on the clinical scenario (Figure 3). Almost all (82.3%) EPs self-reported almost always or often asking a patient with suicidal ideation or suicide attempt (SI/SA) about firearm access, compared to 52.4% of cases where patients presented as victims of domestic violence, and lower rates for patients with psychosis or intoxication (11.7%). Knowing that a patient had access to a firearm would reportedly increase concern of future risk of violence or self-harm for 91.7 % for suicidal patients, vs only 46.6% of assault-injured patients (Figure 4). Knowing that a patient had access to a firearm would change an EP's assessment of a patient only rarely, except for suicidal or psychotic patients (Figure 5). When asked about counseling, however, less than half (46.9%) of respondents reported "almost always" or "often" counseling suicidal patients and their families on lethal means.

Figure 3.

Frequency of asking a patient about firearm access in different scenarios. (Total n = 1,710)

Figure 4.

Knowledge of a patient's firearm access changes assessment of risk of harm. (Total n=1,711)

Figure 5.

The proportion of participants that changed their assessment about a patient's risk of future violence/self-harm if the patient was intoxicated/substance impaired (n = 1,704), psychotic/agitated (n = 1,704), injured in an assault (n = 1,703), suicidal (1,710), and/or a victim of domestic violence (1,707). Total participants who answered this question n = 1,711.

Differences in responses were observed between respondents with a firearm in the home, and those without a firearm in the home. Although the majority (79%) of respondents with a firearm in the home believed that they had the training necessary to educate/counsel patients on firearm injury prevention, only 38.1% believed that other EPs were knowledgeable on firearm injury prevention. Of the EPs who strongly agreed that they wanted additional training in procedures to both identify and counsel patients at risk, only 26.4% and 22.9%, respectively, were gun owners (vs 73.6% and 77.1% non-gun owners; P<0.0001). Of EPs who strongly agreed that counseling would change how patients stored their firearms, only 34.4% were gun owners (vs 65.6% non-gun owners; P<0.0001). Compared to those without a firearm in the home, respondents with a firearm in the home were less likely to report that knowing a patient had firearm access changed their assessment about their risk of future violence/self-harm for a victim of domestic violence (30.6 vs 69.4%), a suicidal patient (38.2% vs 61.7%), an assault-injured patient (27.2% vs 72.8%), a psychotic/agitated patient (37.1% vs. 62.9%), or an intoxicated/substance impaired patient (27.9% vs 72.1%) (P<0.001). Yet respondents with firearms in the home more frequently reported asking about lethal means compared to non-gun owners (almost never asked: gun-owners 68%; non-gun owners: 32%; P<0.0001).

When asked, "How big a concern for you is your personal safety associated with firearms while you are working in the ED?," only 7.7% responded "no concern at all"; 25.3% expressed "very great concern"; 36.8% expressed "moderate concern"; and 30.1% expressed "some concern." Almost 40% (n = 654) of EPs responded that they did not know whether their ED had a procedure for securing patient firearms, and 9.8% said that no protocols existed. Respondents with a firearm in the home were less likely to report concern about their personal safety while working at the ED (very great concern: 35.9% gun owners vs 64.1% no gun owners, P<0.0001).

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