Future physicians and firearms: the need for additional training in firearm injury prevention counseling.

Firearm injury is a major public health issue, with a significant impact on society in both economic and human terms. (1-5) Physicians can be involved in the prevention of firearm injuries and many professional medical organizations have policy statements with firearm injury prevention strategies. (1-8) One role outlined for physicians in many of these policy statements is counseling patients, parents and families on the risks of firearm injury and the formation or continuation of safe household firearm storage practices. (2,5) Physicians who interact with families with children are strongly encouraged to counsel parents on the elimination of guns from their homes and from other environments where their children play. (1,5) In the event that patients or parents choose not to remove guns from the home, it is recommended that they should be counseled to store all their guns in a safe manner, which is locked and unloaded, with the ammunition locked and stored in a separate location.

While professional organizational policies provide important recommendations, physicians' interactions with their patients or patient's families are often influenced by their own personal beliefs and behaviors. Research has revealed that 29% of internists of the American College of Physicians and surgeons of the American College of Surgeons who were surveyed in 1998 and 2000 owned guns. (9,10) National surveys of practicing pediatricians generally have reported lower proportions of firearm ownership (14-16%), (11-13) though regional samples of pediatricians in Alabama and Washington have reported higher proportions of ownership (51% and 21% respectively). (14,15) A national study of the household presence of firearms among a multidisciplinary group of women physicians revealed that 17% reported household firearms. (16) There have been few studies of resident physicians. A study of pediatric residents from 9 programs revealed that 9% were gun owners. (17) A national sample of pediatric residents revealed that 7% reported gun ownership. (13)

The study by Frank et al (18) in this issue of the Southern Medical Journal is the first to examine the presence of household firearms among medical students. This study, like those of practicing physicians and residents, demonstrates that medical students generally report lower proportions of household firearms, with some regional variation, than the general population. Unfortunately, like previous research on physician firearm ownership, household firearms and firearm safety counseling, too few medical students report consistently and confidently providing firearm safety counseling.

Although physician firearm safety counseling practices may be influenced by personal beliefs and behaviors, (10,11,14) counseling practices and confidence in providing counseling may also be influenced by medical and public health training. Medical school, where the foundation of medical knowledge is laid, may be the perfect place to institute this training. As indicated by this study, by senior year only 12% reported having had extensive firearm safety training and only 28% of students reported that they were highly confident in talking to patients about firearm possession and storage. Alarmingly, only 34% of students reported counseling patients about firearm possession and storage more than "never/rarely" and only 4% reported "usually" or "always" offering such counseling.

As indicated by the study, when developing firearm injury prevention counseling curricula, it may be important to consider whether the students have household firearms since those with household firearms may be less likely to provide counseling. It may also be useful to ask students to examine their own households for gun ownership, storage practices, and potential risk factors for firearm injuries such as the presence of children, binge and heavy alcohol consumption, suicidal ideation and feeling blue. It was disturbing that among medical students with self-reported household firearms, 36% reported infrequent or frequent binge drinking, 16% reported ever having thoughts of suicide and 48% reported that they felt blue all or most of the time in the last 4 weeks. Providing them with firearm injury prevention and counseling training which includes risk factors may allow them to make their own homes safer.

While firearm safety counseling is recommended by many professional medical organizations, further studies are needed to determine the effectiveness of firearm safety counseling in changing rates of firearm injuries. There have been some studies outlined in the article and others that have demonstrated effectiveness in changing individuals' storage practices, particularly when counseling is paired with the distribution of safety devices. (19)

Additional studies are also needed to develop effective firearm injury prevention and counseling training programs for physicians. An effort to develop a resident firearm injury prevention counseling curriculum is being organized by the Handgun Epidemic Lowering Plan (HELP). The curriculum will be web-based and initially aimed at pediatric residents. It is intended to be modified and extended to residents from other medical disciplines later. It will provide background on injury prevention principles, epidemiology of gun injuries, counseling strategies and messages, and advocacy. The curriculum will also include an evaluation component. If the program is successful, it may be modified for use by medical students.

References

1. American Academy of Pediatrics Committee on Injury and Poison Prevention. Firearm-related injuries affecting the pediatric population. Pediatrics 2000;105:888-895.

2. American College of Physicians. Firearm injury prevention. Ann Intern Med. 1998;128:236-241.

3. Committee on Trauma of the American College of Surgery. Statement on firearm injuries. Bull Am Coll Surg 2000;85:24.

4. American Association of Orthopaedic Surgeons. Firearms Violence. Available at: http://www.aaos.org/wordhtml/papers/position/1134.html. Accessed September 13, 2005.

5. Duke N, Resnick MD, Borowsky IW. Adolescent firearm violence: position paper of the Society for Adolescent Medicine. J Adolesc Health 2005;37:171-174.

6. Longjohn MM, Christoffel KK. Are medical societies developing a standard for gun injury prevention? Inj Prev 2004;10:169-173.

7. American Academy of Family Physicians. Firearms/Handgun Firearms, Handguns and Assault Weapons. Available at: http://www.aafp.org/x6823.xml. Accessed September 13, 2005.

8. American Medical Association. H-145.000 Firearms: Safety and Regulation. Available at: http://www.ama-assn.org/apps.pf_new/pf_online. Accessed September 13, 2005.

9. Cassel CK, Nelson EA, Smith TW, et al. Internists' and surgeons' attitudes toward guns and firearm injury prevention. Ann Intern Med 1998; 128:224-230.

10. Becher EC, Cassel CK, Nelson EA. Physician firearm ownership as a predictor of firearm injury prevention practice. Am J Public Health 2000;90:1626-1628.

11. Olson LM, Christoffel KK, O'Connor KG. Pediatricians' experience with and attitudes toward firearms: results of a national survey. Arch Pediatr Adolesc Med 1997;151:352-359.

12. Webster DW, Wilson ME, Duggan AK, et al. Firearm injury prevention counseling: a study of pediatricians' beliefs and practices. Pediatrics 1992;89:902-907.

13. Borowsky IW, Ireland M. National survey of pediatricians' violence prevention counseling. Arch Pediatr Adolesc Med 1999;153:1170-1176.

14. Fargason Jr, CA, Johnston C. Gun ownership and counseling of Alabama pediatricians. Arch Pediatr Adolesc Med 1995;149:442-446.

15. Grossman DC, Mang K, Rivara FP. Firearm injury prevention counseling by pediatricians and family physicians: practices and beliefs. Arch Pediatr Adolesc Med 1995;149:973-977.

16. Frank E, Kellerman A. Firearm ownership among female physicians in the United States. South Med J 1999;92:1083-1088.

17. Solomon BS, Duggan AK, Webster D, et al. Pediatric residents' attitudes and behaviors related to counseling adolescents and their parents about firearm safety. Arch Pediatr Adolesc Med 2002; 156:769-775.

18. Frank E, Carrera JS, Prystowsky J, et al. Firearm-related personal and clinical characteristics of US medical students. South Med J 2006;99:216-225.

19. Coyne-Beasley T, Schoenbach VJ, Johnson RM. Love our kids lock your guns: a community firearm safety counseling and gun lock distribution program. Arch Pediatr Adolesc Med 2001;155:659-664.

Tamera Coyne-Beasley, MD, MPH, and Adrea Theodore, MD, MPH

From the Departments of Pediatrics, Internal Medicine, Health Behavior Health Education, and Social Medicine, and the University of North Carolina Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC.

Reprint requests to Tamera Coyne-Beasley, MD, MPH, Adolescent Medicine, Department of Pediatrics, CB# 7220, 130 Mason Farm Road, 5th Floor, University of North Carolina, Chapel Hill, NC 27599. Email: [e-mail]

Accepted December 21, 2005.