In 2018, there were nearly 40,000 firearm deaths in the United States. 1 Firearm injuries are among the 5 leading causes of death in the United States among individuals aged 1 to 64 years. 1 In addition to firearm deaths, which are predominantly suicides, firearm injuries cause significant morbidity; most nonfatal firearm injuries are related to assault and are concentrated in urban settings. 1 The initial hospital costs following firearm injury have been estimated at over $700 million annually, 2 with nearly another $100 million related to readmissions within 6 months. 3
Leading medical professional societies have identified firearm injury and death as a public health threat, and multiple systematic reviews have outlined the current state of the evidence supporting clinician involvement in firearm injury prevention. 4–6 When they engage in firearm safety counseling, clinicians are effective in improving families’ safe storage behaviors. 7–11 Nonetheless, few clinicians have received education on the basics of firearm injury epidemiology, risk factors, or preventive interventions. Medical students, residents, and practicing physicians report low rates of knowledge, self-efficacy, and evidence-based practice related to firearm injury prevention. For example, in a 2016 survey of pediatric residents, only 22% reported having received didactic education on firearm injury prevention and, despite 96% saying they had a responsibility to counsel patients on the risks posed by firearms, only 37% ever provided firearm-related counseling. 12 Similarly, a minority of emergency medicine providers report having received training on firearm safety or counseling. 13,14 According to a 2014 survey of members of the American College of Physicians, 58% said they “never” ask about the presence of firearms in the home. 15
Although qualitative research shows that patients are open to discussing firearm safety with their clinicians, 16,17 fewer than 20% of U.S. firearm owners rated physicians as effective messengers about safe storage practices, such as the application of an external locking device when a locked box or safe is unavailable or unacceptable; this is consistent with prior research suggesting that physicians do not have an understanding of firearm safety or culture. 18,19 These findings highlight the need for training in firearm safety and injury prevention to improve clinicians’ self-efficacy and competence in firearm counseling and thereby increase the provision of firearm counseling.
Integrating firearm injury and violence prevention into health professions education is crucial to ensure that current and future clinicians have the tools and skills to address this issue at the bedside as with any other threat that causes morbidity or death. 20 As yet, this critical need is unmet among undergraduate, graduate, and continuing medical education programs. 21–23 The curricula of health professions schools are designed to train students to meet the health care needs and priorities of the local communities within which they reside and for whom they serve. Although major changes are less frequent, all accredited medical and nursing schools make small changes, or quality improvements, to their curricular structure and content on a regular basis. The Association of American Medical Colleges tracks these changes on an annual basis; from 2015 to 2020, the percentage of schools that included firearm-related content increased from 18% to 27%. 24
Consensus methodologies have been used for curriculum development in nearly every medical specialty and all levels of training throughout undergraduate and graduate medical education. 25–27 The aim of this investigation was to convene a diverse group of national experts in firearm injury epidemiology, injury prevention, and medical education to develop consensus on priorities to inform the creation of learning objectives and curricula for firearm injury education for medical professionals using the well-validated nominal group technique.
We convened an advisory group of content experts on firearm injury epidemiology and medical education and used the nominal group technique to achieve consensus on priorities for health professions education on firearm injury. This work was deemed exempt by the University of California, San Francisco Institutional Review Board.
Advisory group members
We recruited a cohort of experts for our advisory group in April 2019, using a purposive snowball sampling methodology. 28 Prospective members were identified according to a survey of previously published firearm injury research, affiliation with professional societies or organizations with experience in education in firearm injury (including the American Foundation for Firearm Injury Reduction in Medicine and the Association of American Medical Colleges), and recommendations from experts in the field.
We sought a wide breadth of expertise with respect to geography, medical specialty and profession, level of training, and practice setting. We recruited firearm owners, firearm trainers, and veterans. We also purposefully included nonclinical researchers and medical educators with expertise in curriculum development.
We used the nominal group technique 29,30 to develop specific and comprehensive consensus-based priorities across various contexts of firearm injury, educational domains, and concept types. 31 This technique allowed for data collection and consensus development through the engagement of a group of experts. 32,33 The process involved an initial idea-generating phase, followed by a round-robin sharing of ideas and further idea generation, facilitated discussion and clarification, and the ranking of ideas to generate a prioritized list. Nominal group technique allows for the generation of a large list of prioritized ideas and reduces biases from excessive influence by individual perspectives. 29,30 Because our goal was to develop a compendium of educational priorities, the nominal group technique was deemed to be superior to the Delphi technique, which attempts to converge on a final opinion. 29,30
We chose to focus our work on 7 contextual categories relevant to firearm injury that have previously been identified in the literature: 1 category of general, crosscutting priorities applicable to all contexts and 6 categories of specific contexts of firearm injury, including intimate partner violence, mass violence, officer-involved shootings, peer (nonpartner) violence, suicide, and unintentional injury. 32,33 For consistency with an injury prevention framework, we note that the specific contexts of injury may be interchangeable with the “intent” of injury. Firearms are the mechanism of injury for all contexts.
Given the wide geographic distribution of the advisory group, we convened entirely via teleconferences and online surveys to maximize participation by all members. After an initial 1-hour introductory meeting in July 2019, we held two 4-hour meetings in September and October 2019. After each meeting facilitated by the advisory group chairs (K.H., J.F.), we deployed an online survey. We collected advisory group member participation data for each step of the process. In addition to recording the meetings, 2 study investigators (L.K. and C.S.) captured detailed meeting minutes. During the meetings, we allowed for time so that all ideas and perspectives could be voiced, and members had the option to message the group via the chat function rather than speak (or message the advisory group chairs privately). The advisory group chairs made note of the less vocal members of the group and contacted those individuals personally to solicit feedback and ideas. All teleconferences were held via Zoom (Zoom Video Communications, San Jose, California), and online surveys were created and distributed using Qualtrics (Qualtrics, Provo, Utah).
Phase 1: Silent idea generation phase: Literature review and the identification of initial priorities.
Our initial idea-generating survey asked each advisory group member to contribute 2 to 10 educational priorities for the general and context-specific categories based on their individual knowledge and review of the firearm injury literature. Members with expertise in a specific context of firearm injury contributed at least 5 priorities related to that context. The advisory group chairs organized the submissions into educational domains (epidemiology, screening and counseling, cultural humility, medical management, interprofessional education, health systems improvement, health policy, ethics, and firearm basics), which were guided by the content of the submissions.
Phase 2: Round-robin phase: Presentation of priorities and continued idea generation.
For each of the 7 categories (1 general and 6 context-specific) of firearm injury, suggestions for educational priorities organized into the 9 educational domains above were sent by email to the advisory group members for review before an initial round-robin meeting. The term “round-robin” is used to describe the circulation or discussion of an idea within a group for the purpose of sharing comments and other ideas. During this meeting, moderated by the advisory group chairs, the priorities and domains were modified, consolidated, and recategorized through group discussion.
Phase 3: Clarification phase: Iterative refinement of priorities.
Advisory group members divided into context-specific subgroups according to self-identified areas of expertise to further refine and clarify the priorities and ensure completeness. This work was completed via email over 2 weeks. The advisory group chairs were included in all communications, but revisions were led by members of the subgroups.
Phase 4: Ranking and voting phase: Ranking survey and consensus generation.
When the subgroup revisions were complete, a ranking survey was disseminated to the full advisory group. Members assigned a rank order to the priorities within each educational domain. The results were sorted and shared in advance of a consensus-generating meeting. We relied on group discussion during this meeting to determine the priorities of least importance to exclude from our list.
Based on group discussion in the consensus-generating meeting, the potential educational domains were narrowed to epidemiology and social context; patient-centered care; and ethical, legal, and policy implications. Within the general section, we included firearm anatomy and physiology and health systems improvement.
Phase 5: Finalizing educational priorities phase: Final survey and external expert review.
To determine consensus, the advisory group members voted to include or exclude each of the remaining priorities on the final list. Consensus was defined as approval by ≥ 75% of members to include a priority. The priorities for the officer-involved shooting context of firearm injury did not undergo further refinement as none of the priorities reached the threshold for consensus.
Advisory group members were provided space to offer additional feedback, such as grouping similar priorities sharing a common topic or theme, and the advisory group chairs considered this feedback for further editing of the priorities. Standardized language using Bloom’s taxonomy was used to create action-oriented statements commonly used in curriculum development. 34 At this point, it was decided that the health systems improvement priorities, while important, should be considered separately for the purposes of curriculum development given their greater relevance to organizations and health care systems than to clinical educators.
Per advisory group feedback, in addition to organizing the priorities according to contextual and educational categories, we also assigned concept types: “basic” concepts that form a foundation for firearm injury education important to all learners, “complex” concepts that represent higher level or more nuanced priorities in firearm policy or outcomes, and “threshold” concepts that potentially could lead to a qualitatively different view of the subject matter or learning experience. 31 Concept types are not ordinal; specifically, a threshold concept is not, by definition, more complicated or difficult to master than basic or complex concepts.
At this stage, 3 external experts (2 in firearm injury and 1 in medical education) who were not part of the advisory group reviewed the list of priorities and provided feedback. The advisory group chairs made revisions based on this feedback and sent the revised list to the advisory group members for final review, which did not result in any further revisions. The list of priorities was considered finalized at this point.
Our advisory group was geographically, demographically, and professionally diverse, with 33 members from across the United States. Geographically, 12 (36%) members were from the West, 9 (27%) from the South, 7 (21%) from the Northeast, and 5 (15%) from the Midwest. Practicing physicians accounted for 23 (70%) members, many of whom had dual roles in research, public health, or education. Ten (43%) of the 23 physician members were from emergency medicine, with the remainder distributed among family medicine, internal medicine, pediatrics, psychiatry, and surgery. Four (12%) members were medical students, 3 (9%) were from nursing, 2 (6%) were primarily in public health, and 1 (3%) was primarily a medical educator. Eight (24%) members were firearm owners, and 7 (21%) had military affiliations. Additionally, 8 (24%) members identified as persons of color.
Each meeting had more than two-thirds participation, and each survey had more than 87% participation. Twenty-nine members responded to the initial idea-generating survey, resulting in 613 overlapping priorities, which represented 111 unique themes. After review at the first consensus-generating session, 141 unique priorities remained, which were then ranked by the advisory group. After reviewing the rankings and consolidating the themes during the second consensus-generating session, 89 priorities remained. A total of 58 educational priorities were approved by 75% or more of the advisory group. Based on additional feedback from the advisory group and external reviewers, as well as further editing and consolidation by the advisory group chairs, a total of 51 final priorities were included in the consensus recommendations. Figure 1 diagrams the consensus-generating process and outcomes. The distribution of the final priorities across the contexts of injury and educational domains is summarized in Chart 1.
The final list of priorities for health professions education on firearm injury, grouped by contextual categories and educational domains, can be found in Appendix 1. Concept types (basic, complex, and threshold) are also shown for each priority. For example, all learners receiving basic education on unintentional firearm injury prevention should be able to “describe measures to reduce unintentional injury risk in the home including but not limited to firearm removal, safe storage, safe handling, safety training, education at the point of firearms sale, shooting sports education, and injury prevention education in schools.” Priorities relating to health systems improvement are shown in List 1.
Health Systems Improvement Priorities for Health Professions Education on Firearm Injury
- Develop screening for firearm suicide, unintentional injury, and homicide risk in patient visits, and incorporate appropriate interventions, resources, and counseling when a patient is identified as being at increased risk for firearm injury.
- Develop and implement appropriate documentation of firearm injury risk and of counseling provided in clinical encounters as well as clinically appropriate after-visit summary information.
- Devise institutional policies governing safe handling and storage of a firearm if brought by a patient or visitor to a health care setting.
- Provide training for active shooter scenarios specific to the health care setting, with attention to duty to care.
To our knowledge, this report describes the first national consensus guidelines on firearm injury education for medical professionals. These guidelines provide a set of educational priorities that are applicable to all contexts of firearm injury and all medical disciplines and levels of training. The guidelines highlight areas in which there is evidence for the efficacy of various policies or practices (e.g., licensing or counseling on safe storage), which we highlight below. They cover material that should be understood by clinicians in all disciplines and specialties.
Each set of priorities within a contextual category lays out educational content that is focused on that context of firearm injury with particular attention to epidemiology, risk factors and risk assessment, and prevention strategies at the population level and in the hospital setting. Below, we briefly summarize our priorities for each firearm injury context with references to the literature that informed the development of the corresponding guidelines. In some instances, we provide recommendations for implementation.
Medical professionals should understand the relationship between firearm access and risk of homicide in intimate partner violence, including how this effect may be modified by a multitude of cofactors, such as gender identity, race, and substance use. 35,36 Violence toward an intimate partner may also extend to others, including children or oneself. 37,38 Our priorities focus on screening, including targeted screening in high-risk situations, followed by coaching and counseling to mitigate injury and risk as there is tremendous nuance in mitigation strategies specific to individual circumstances. 39,40 Clinicians must be prepared to navigate a variety of challenges when patients are at high risk of attack from their partners (e.g., safety planning, controlling firearm access, potential for escalation, need for social resources). 41,42 These scenarios may be further complicated by mandatory reporting and by laws governing firearm safekeeping and removal. 43
While mass shootings garner (and to an extent may be motivated by) a disproportionate share of media and policymaker attention, they represent an extremely small fraction of firearm injuries. 44,45 These events, while rare, have overlapping risk factors and phenomenology with other contexts of firearm violence, especially suicide and intimate partner violence. 46,47 Tools to prevent targeted and mass violence, such as extreme risk protection orders and threat assessment, are important for clinicians to understand and use to prevent future attacks, especially because the psychological impacts of mass shootings are profound and lasting for survivors and medical professionals alike. 48–50
Peer (nonpartner) violence is an important contributor to firearm-related morbidity and mortality; indeed, it is the leading cause of death among non-Hispanic, Black American males aged 15 to 34 years. 51,52 Our advisory group prioritized understanding the epidemiology of these injuries 53; the role of the social determinants of health 54; and evidence-based policies, 55–57 programs, 58 and strategies 59 that can reduce peer violence. Our advisory group had consensus that medical professionals should be trained in best practices for screening and counseling victims of peer violence 60 and understand the role and effectiveness of hospital- and community-based violence prevention programs. 61,62 We recommend that these priorities be incorporated into core course requirements including, for example, simulated patient encounters using a trauma-informed approach and continuing education on community-based violence intervention programs. With appropriate training, medical professionals have a unique opportunity to apply evidence-based strategies and interrupt the cycle of peer violence.
For firearm suicide prevention, our advisory group prioritized educating clinicians about the risk factors for suicide and understanding how short-term spikes in suicidal intent 63–65 and access to a highly lethal, 66,67 fast, and nonreversible suicide method increase the risk of a fatal outcome. 68–71 When a patient is at risk for suicide, clinicians should be comfortable counseling on the reduction of access to lethal means with patients and families as part of a suicide safety plan 72 or general safety discussion. 73–76 In our consensus guidelines, a motivational interviewing approach is described that respects patients’ decisional autonomy (in the absence of acute risk requiring emergency intervention) and is aimed at solutions, such as storing firearms away from the home or locking firearms and having a friend hold the key until the patient recovers. Clinicians should be familiar with institutional and state-specific policies regarding safe storage, 77,78 temporary transfers, 79 and emergency firearm access restriction. 80,81 Firearm access should be recognized as an important element of suicide risk and firearm owners as critical partners in prevention.
Regarding education about the prevention of unintentional firearm injuries and deaths, our advisory group prioritized the identification of high-risk behaviors for unintentional injury and understanding the mechanisms by which these risks might be mitigated, including safe storage and safety training. For example, when providing routine age-based anticipatory guidance, clinicians should be aware of state child access prevention laws, be comfortable counseling on safe storage methods (including options for when a firearm is owned for personal protection), and know that a majority of firearm owners support safe storage and that physicians can be effective at motivating families to adopt safe storage behaviors. 7,82 These priorities should be integrated into education on relevant state and local policies or through hands-on training to improve physicians’ self-efficacy in counseling on the application of safety devices.
Our consensus guidelines are reflective of the current state of research and should be considered a living document that will need to be adapted to incorporate new study findings as the evidence base continues to grow. Much of this material is best presented (and to a degree already being presented) interwoven throughout existing curricula. The intent of this phase of our research was not to develop a complete curriculum nor a series of educational modules. These priorities will need to be interpreted and applied to each program and school according to their unique educational needs. Challenges and barriers to implementation will need to be considered by educators (e.g., alignment with existing curricula, tensions related to constraints in available curricular time, faculty development).
Furthermore, some types of firearm injury and death disproportionately affect racial, ethnic, sexual, and gender minorities. 83,84 These priorities must also be interpreted and applied to broader educational efforts addressing equity and structural racism. It is important to recognize that each school and program exists within a larger health system. The health systems improvement priorities in List 1 are reflective of institutional-level requirements that are critical for creating a clinical learning environment that facilitates learners’ ability to apply lessons learned in the classroom to hands-on patient care.
Officer-involved shootings, while not well characterized, have resulted in about 1,000 deaths each year for the last 6 years. 85,86 They are an important cause of death and injury in the United States and are critical topics on which medical professionals must be well informed, especially with respect to discussions of how structural violence and racism impact health and well-being. Furthermore, officer-involved shootings have direct effects on patients and communities as well as on health care systems and society. The failure of any priority in this context of firearm injury to reach the 75% threshold for consensus for inclusion is indicative of the need for further research to inform the development of robust, comprehensive educational priorities. It is also indicative of the lack of perceived clinician efficacy in addressing this societal problem. As universities and hospitals increasingly recognize their roles in dismantling structural racism, addressing officer-involved shootings will become an important component of health professions education. We have chosen to include these priorities in Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/B141 to serve as a foundation for future work.
Future research should examine the implementation and validation of these objectives, specifically studying their use in educational program development (e.g., measures of implementation efficacy, continuous quality improvement, learner evaluations) and the downstream effects of improved clinician education on firearm injury. Downstream effects could be assessed using outcome measures such as the frequency of counseling, rate of patient uptake of safe storage behaviors, and patients’ perceptions of clinicians as effective messengers about firearm safety.
These findings must be considered in the context of some limitations. First, educational topics or areas not included in this analysis may reflect lack of consensus knowledge or standards; these guidelines will therefore be subject to revision as knowledge changes. We also did not attempt to prioritize certain topics for clinicians practicing in different settings (e.g., rural versus urban), further emphasizing the need for tailoring this curriculum to the needs of a given program or practice. While our advisory group members were carefully selected to be highly inclusive, with respect to national demographic data, our cohort underrepresents the South and minority groups relative to the population, with about 25% of our group comprising individuals who identified as people of color. 87 We also overrepresented emergency medicine clinicians, with nearly a third of our group consisting of emergency physicians and nurses. While we intentionally included firearm experts, we did not attempt to include representatives from community organizations.
In addition, not all members were able to participate in each meeting, and it cannot be known how full involvement might have altered the final language of the priorities. We were unable to convene every expert in the field of firearm injury and some influential clinician–researchers were not included in our advisory group. Although bias is possible in any consensus technique, the nominal group technique is specifically designed and implemented in such a way that minimizes undue influence by any individual or group by allowing for both open and anonymous feedback in multiple formats.
In conclusion, physicians consistently indicate that they feel a responsibility to counsel patients and families on firearms and injury risk. 12,88 Yet, when only about 20% of physicians have received education on any aspect of firearm injury, it is not surprising that many do not feel well equipped to provide this counseling and that patients do not find physicians to be credible messengers about firearms. 12,13,18 Robust, data- and consensus-driven priorities for health professions education on firearm injury create a pathway to clinician competence and self-efficacy. With an improved foundation for curriculum development and educational program-building, clinicians will be better informed and poised to engage in a host of firearm injury prevention initiatives both at the bedside and in their communities.
The authors gratefully acknowledge the participation of additional members of the Consensus-Driven Priorities for Firearm Injury Education Among Medical Professionals consortium: Dr. Sue Bornstein, Dr. Jacquelyn Campbell, Dr. Patrick Carter, Ms. Robin Cogan, Dr. Eric Goralnick, Dr. Nikita Joshi, Dr. Joneigh Khaldun, Dr. Torree McGowan, Dr. L.J. Punch, Dr. Robert Riewerts, Dr. Barry Solomon, and Dr. Jason Theis. They also acknowledge the shared expertise of the external reviewers, Dr. Sandra McKay and Dr. Deborah Kuhls, who reviewed the final priorities.
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Appendix 1 Priorities for Health Professions Education on Firearm Injury, Developed by Consensus by an Expert Advisory Group, 2019