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

Discussion

To our knowledge, this study is the most comprehensive assessment to date of EPs' attitudes, beliefs, and self-reported behaviors in relation to firearm injury prevention in the clinical setting. Despite respondents representing a convenience sample, the percent of respondents with a firearm in their home is similar to that reported in national surveys, and the geographic, gender, and racial/ethnic distribution of the respondents is similar to that in national data on emergeny medicine.[22] Among this diverse sample of EPs, despite half reporting no barriers to asking high-risk patients about firearm access, numerous training needs were identified. The most notable findings were the disparities between reported knowledge, attitudes, and normative beliefs about the values of screening vs actual reported counseling of high-risk patients. There were stark disparities between what respondents said they did, and what others did. Differences in knowledge, attitudes, and beliefs about screening and counseling were also observed between firearm owners and non-owners.

Reassuringly, our survey identifies that neither knowledge nor normative beliefs are major barriers to firearm injury screening and counseling for high-risk patients. Most respondents reported knowing how to ask, and most reported that a positive finding would affect their judgment (but not necessarily their behavior) regarding evaluation of an at-risk patient. Only 8.6% reported being afraid to ask a patient about access to a firearm. This finding differs from other surveys of other physicians' knowledge and attitudes, which reported low rates of knowledge about the incidence of firearm injury and discomfort with asking about firearms.[25] This difference may reflect multiple medical societies' educational efforts over the last half-decade emphasizing that patients are open to respectful, non-judgmental discussions of firearm injury risk.[26,27]

According to this survey, the two primary barriers to EPs' effectively screening and counseling ED patients about firearm injury were not knowing how to respond to the information, and not thinking it will change management. Lack of resources, and skepticism about efficacy has been identified by others[22,25–28] as common barriers to effective firearm injury prevention in the ED. Our findings, therefore, reinforce the importance of physician and patient self-training resources and handouts, In 2019, Pallin et al published a guide to when and how to intervene to reduce firearm injury.[11] In response, multiple resources have been recently developed, including the following: 1) "What You Can Do" and "BulletPoints," initiatives from University of California at Davis;[29] 2) "Gun Safety and Your Health" (available in both English and Spanish) from the American College of Surgeons;[30] 3) Guides to home firearm safety and pediatric counseling from the Firearm Safety Among Children and Teens (FACTS) Consortium;[31] 4) safe storage resources from the Colorado Firearm Safety Coalition;[32] and 5) a compendium of resources from the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM), a non-partisan network of health professionals dedicated to changing the conversation about firearm injury prevention.[33] Emergency departments interested in decreasing barriers to screening and intervention could review and share these well-developed resources.

In line with national surveys, having a firearm in the home was more common among White men, those practicing in rural areas and small cities/towns, and those who believe that gun ownership is a constitutional right, a personal liberty, and a self-protection.[34] Those EPs with a firearm in the home were more likely to ask patients about lethal means, reported less concerns about their safety while working at the ED, were less interested in wanting additional training to identify patients at risk, and were less likely to agree that counseling would change how patients stored their firearms. Additionally, EPs with a firearm in the home were less likely than those without a firearm in the home to report insufficient knowledge about how to ask. These findings concord with our and others' work showing that firearm owners can help lead evidence-based interventions to reduce firearm injury risk.[22,28,35–37] Future educational programs should make an effort to highlight the voices, expertise, and experience of firearm-owning EPs.[37,38] Nonetheless, deficits in knowledge were identified among this group, including lack of belief in the value of screening or counseling for patients who were at risk of non-suicide-related firearm injury.

The findings also suggest, unfortunately, that simple knowledge alone is unlikely to change behavior. For example, despite most participants reporting that screening is important and would change their behavior, and most respondents saying that they personally were comfortable with firearm counseling, almost all said that other EPs were not comfortable screening or counseling at-risk patients, and most requested at least some additional training for themselves. Similarly, despite most participants reporting that they "always or almost always" screen suicidal patients for firearm access (much higher than previous literature has reported),[20,26,39] and most participants reporting that this knowledge would change their disposition decision for suicidal patients, less than half report delivering lethal means counseling. These incongruities may reflect social desirability bias (e.g., it may be easier for respondents to admit that others were unsure of what to do or how to do it, compared to admitting it about themselves). Others' work has studied physicians' actual behavior, using both electronic health records and self-report, and has similarly found that physicians screen far less often than self-report.[11,26,39,40] Even if a large percentage of subjects in this study are asking patients with suicidal ideation about firearm access, competent counseling should be part of the discussion.[20]

The contradictions in responses may reflect a key lesson of behavior change theory[41,42] and dissemination and implementation research: Attention must be paid to not just internal factors, but also healthcare and societal structures that influence change.[42] For example, Runyan et al have suggested that having departmental written protocols for lethal means counseling has been associated with a higher rate of counseling for all suicidal patients, and that developing such standard protocols across the country might increase lethal mean counseling.[40] Betz et al have developed physician-independent, web-based, lethal means counseling resources, with high acceptability and feasibility.[43] Development and dissemination of similar resources that reduce physician burden and address physician-independent barriers may be necessary.

Finally, our data confirm that EPs were significantly concerned about their safety associated with firearms while working in the ED, with a quarter expressing "very great" and more than a third expressing "moderate concern" about their personal safety. This concern is exacerbated by both a lack of policy regarding firearm handling, and a lack of knowledge of any existing policies; the majority of respondents reported that they are concerned for their own safety, yet a third had no idea whether a policy existed. This finding could potentially be explained by several factors including physicians' attitude toward the subject, professional priorities, or a lack of education or communication on the topic from ED leadership. In a survey conducted by Ketterer et al, 20% of attending and 25% of resident physicians reported encountering firearms in the ED or its immediate surroundings. Attending physicians, however, had more knowledge of hospital policy regarding handling and management of the firearm once it was discovered in a patient's possession, as compared to residents.[22–28] In another study Ketterer et al reports that "up to 25% of trauma patients brought to the emergency department (ED) have been found to carry weapons."[28] Overall, more research is needed to address safety in the ED and the handling of firearms when they are brought into the department; further collaborative work is needed.[24,45]

The American College of Surgeons' Committee on Trauma[23] published results from a similar survey of surgeons in 2016, with the primary objectives of identifying advocacy initiatives and efforts related to firearm safety. Our respondents were similar to ACS' in demographics, percent firearm ownership, percent with gun safety training, and percent with a military background; the one major difference is that our EM survey included resident physicians, while the ACS survey did not. ACS found that the vast majority of respondents believed that healthcare professionals should be allowed to counsel patients on firearm safety and injury prevention, with 88% setting injury prevention as a high priority and 94% responding that federal funding should be allocated for firearm safety and injury prevention research.[23] Our study, conducted two years later after extensive educational work by both ACS and EM professional societies,[7,45] assumed that healthcare professionals have the duty to discuss firearm safety and injury prevention with at-risk patients, and sought instead to determine how often these conversations were taking place (< 50% of encounters with suicidal patients), how comfortable physicians were in having these conversations (51.4%), and what percentage of physicians felt the need for further training to effectively engage patients in these conversations (>70%).

The overarching theme of our organizations, institutions and collaborations is to explore shared goals among healthcare professionals, public health researchers, educators, advocates, firearm owners, gun shops,[46] and law enforcement officials who are collectively committed to working toward suicide prevention and firearm safety.[32] Our study supports the need for increased training and protocols regarding firearm counseling, handling, and medical record documentation. Physicians are aware of the lack of training and are open to learning the necessary skills to save lives through education and prevention of firearm injuries. Further research is needed on the efficacy of current training and available resources.

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