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Exploratory qualitative study of firearm storage practices among surgeons in the USA: contexts and motivations

Background

A US survey of surgeons found that 32% store firearms unlocked and loaded. This study explored conditions and contexts impacting personal firearm storage methods among surgeons.

Methods

We conducted semi-structured interviews with English-speaking fellows of the American College of Surgeons who treated patients injured by firearms and who owned or lived in homes with firearms. Participants were recruited through email and subsequent snowball sampling from April 2022 to August 2022. All interviews were audio-recorded and transcribed verbatim. Thematic analysis was applied to transcripts to identify codes. A mixed deductive and inductive approach was used for data reduction and sorting.

Results

A total of 32 surgeons were interviewed; most were male and white. Dominant themes for firearm storage practices were based on (1) attitudes; (2) perceived norms; (3) personal agency; and (4) intention of firearm use. Personal agency often conflicted with attitudes and perceived norms for surgeons owning firearms for self-defence.

Conclusions

Storage practices in this sample of firearm-owning surgeons were driven by intent for firearm use, coupled with attitudes, perceived norms and personal agency. Personal agency often conflicted with attitudes and perceived norms, especially for surgeons who owned their firearm for self-defence.

Attitudes toward physician-provided gun safety counselling among current and prospective gun owners in the USA

Background

Americans increasingly perceive that homes with guns are safer than those without, and physician counselling about in-home firearm safety and injury risks occurs infrequently, despite encouragement from major medical organisations (eg, American Medical Association, American Academy of Pediatrics). Safety counselling that does occur may be limited to gun owners at high risk of injury; however, given the increasing rates of first-time gun ownership in the USA, understanding attitudes toward firearms and firearm safety messaging among persons who may become firearm owners is needed to inform and support continued injury prevention efforts.

Methods

Survey data from a cross-section of firearm owners (n=396) and non-owners (n=551) collected in February 2023 was used to examine differences in perceptions about the safety of firearm households, openness toward firearm safety counselling and comfort with law enforcement compared with physician firearm safety discussions.

Results

Over three-quarters of current and possible future gun owners agreed that firearms make homes safer, compared with just over one-third of non-owners. All three groups favoured law enforcement over physicians for firearm safety messengers and were more comfortable speaking with law enforcement than physicians about firearm safety.

Discussion and conclusion

Public health and injury prevention safety counselling that combines messaging from law enforcement and medical perspectives may be similarly accessible for both current firearm owners and those considering owning firearms in the future.

Education for healthcare professionals and firearm injury

Background

There is consensus on the need and ability to address firearm injury risk in healthcare settings; however, the lack of education for healthcare professionals hinders the implementation of evidence-based firearm injury and mortality prevention strategies. The objectives of this study are to develop, disseminate and evaluate education for team members to facilitate implementation in emergency departments

Method

Two-tiered education was developed in partnership with stakeholders and disseminated to the healthcare team, covering evidence-based screening and interventions for firearm access and violence risk. The implementation, development and dissemination strategies followed the framework used for systemwide Screening, Brief Intervention and Referral to Treatment implementation for substance use. Team members who screened patients for firearm injury risk received screening education and team members meeting with patients who screened positive received intervention education. Participants completed surveys to evaluate the education and learning objectives.

Results

Across three emergency departments from March 2021 to May 2022, 267 team members completed screening education. Key takeaways reported by 173 participants were how to screen (24.9%), the 5L’s of Firearm Safety (19.7%) and the prevalence of firearm injury (11.0%). Participants still had questions about workflow, resources and safety. 34 of 67 (50.7%) intervention education participants completed the postsurvey. 100% were confident they could screen, 79% were confident they could provide brief interventions and 88% were confident their site could implement firearm injury prevention strategies.

Conclusion

Tiered education for firearm injury prevention screening and intervention achieved learning objectives and facilitated programme implementation. Education increased knowledge and confidence regarding firearm injury risk screening and its importance in healthcare settings.

Firearm Policy in the Hospital Setting

To the Editor In their article, Mr Romero and colleagues discussed the consequences of recent Supreme Court decisions on the possession of firearms, especially the possibility that declaring hospitals a firearm-free domain breaches Second Amendment rights. If that is true, then it applies to hospital staff as well as patients and their relatives. How will patients feel about their physician having an AR-15 on their desk during an examination?

Local Exposure to School Shootings and Youth Antidepressant Use

While over 240,000 American students experienced a school shooting in the last two decades, little is known about the impacts of these events on the mental health of surviving youth. Using large-scale prescription data from 2006 to 2015, we examine the effects of 44 school shootings on youth antidepressant use in a difference-in-difference framework. We find that local exposure to fatal school shootings increases youth antidepressant use by 21.4 percent in the following two years. These effects are smaller in areas with a higher density of mental health providers who focus on behavioral, rather than pharmacological, interventions.

In Search of Common Ground: Expert Judgments on Gun Policy Effects

As our review of the existing literature demonstrated, there is very little scientific evidence available to support the decisions that policymakers and the public must make about whether to implement or change various gun policies. Without strong scientific evidence, policymakers and the public rely heavily on what advocates or social scientists believe the effects of policies are most likely to be. The opinions of these gun policy experts are an important influence on gun policy debates and decisions because people believe that the experts have an especially well-informed understanding of the gun polices under consideration, how similar laws have performed historically, and how specific policies would affect particular stakeholder groups.

Different communities of gun policy experts have sharply divided views on many gun policies, as often becomes clear in the debates that occur when states and the federal government consider new gun legislation. Less clear is whether there are laws or policies for which such differences are less stark, or whether there may be a combination of policies that experts of every stripe could regard as an improvement over existing policies. Finally, it has not been clear whether experts disagree about which objectives gun policies should be trying to achieve or whether experts agree on the objectives but disagree on which policies are most likely to achieve those objectives. If the experts chiefly disagree on the latter, this suggests a role for new and better scientific study of the true effects of gun policies.

To begin to answer these questions, RAND researchers surveyed 173 gun policy experts (across two fieldings in 2016 and 2020) on what they believed the effects of the following 19 gun policies would be on ten different outcomes.

Healing the Healers – Supporting Physicians After Mass Public Shootings

As a disaster mental health (DMH) professional, I have responded to five mass public shootings since 2017 and have had the opportunity to provide support to hospitalized survivors as well as their loved ones. I’ve stood in emergency departments and intensive care units in Uvalde, Texas, Las Vegas, Nevada, and Lewiston, Maine. I have watched dedicated physicians work tirelessly to save the lives of fellow community members. I have heard stories of their heroism, and I have witnessed it with my own eyes. Yet, despite their significant role in the aftermath of these incidents, this group has been largely overlooked in academic literature, and their voices have often been excluded from discussions surrounding mass public shootings. In recent years, physicians have attempted to make their voices heard by tweeting photographs and stories about their experiences treating victims of gun violence using the hashtag “ThisIsOurLane,” a movement initiated by Brady Center to Prevent Gun Violence board chair and chief medical officer Dr. Joseph Sakran. Through these graphic images and narratives, it is clear that these healthcare professionals are profoundly impacted by what has been referred as a gun violence epidemic.

The Psychological Toll

Physicians are not immune to the physical and psychological effects of trauma. Due to the nature of their careers, these individuals often work long hours in high-pressure environments, frequently leading to exhaustion and burnout, particularly in emergency medicine (EM) settings. One recent study found that 15.8 percent of EM physicians and 29 percent of EM residents meet the criteria for posttraumatic stress disorder (PTSD). Additionally, up to 40 percent of trauma surgeons have posttraumatic stress symptoms (PTSS), with 15 percent meeting the full diagnostic criteria for PTSD. While these physicians frequently treat individuals affected by gun violence, when treating victims of mass public shootings, the prevalence of PTSS and PTSD among physicians may be even higher, as research suggests that exposure to human-made disasters can lead to increased levels of distress, especially considering the volume and severity of patient presentations. Furthermore, these physicians often live in the communities affected by these incidents, and some may even personally know the victims they are treating, especially in rural communities and smaller towns, potentially exacerbating their risk of experiencing both short- and long-term stress reactions. However, the needs of these medical professionals are frequently neglected during recovery efforts, and due to this, physicians have been considered unrecognized survivors of mass killings.

The needs of these medical professionals are frequently neglected during recovery efforts, and due to this, physicians have been considered unrecognized survivors of mass killings.

Recently, Dr. Craig Goolsby, Department Chair and Professor of Clinical Emergency Medicine at Harbor-UCLA, convened a group of emergency medical services (EMS) professionals, EM physicians, and surgeons who responded to six high-fatality mass shootings in the US. Their objective was to develop consensus recommendations for improving care and patient outcomes during these tragic incidents. Among their eight recommendations in the final report was the inclusion of tailored mental health services for all responders, whether present at the scene or the hospitals. While the experiences of other first responders, such as EMS, and other hospital personnel, like nurses, have been explored, less is known about physicians. Therefore, in collaboration with Dr. Goolsby, my research colleagues and I conducted a qualitative study using semi-structured individual interviews to explore the experiences and needs of physicians following mass public shootings. More specifically, our research centered on nine physicians in seven impacted communities. While a previous study examined the experiences and immediate needs of physicians working in hospitals located in communities impacted by mass public shootings, our study focused on the ongoing needs of these medical professionals across all disaster phases.

Our findings revealed that these incidents significantly affected most participants in the short term. Many shared how they initially compartmentalized their emotions and struggled to process what had happened. For instance, one participant shared, “it ended up being like, oh, wow, what was that about when I ‘woke up’ two days later…I remember getting home after another busy shift and just breaking down.” Participants also described how these incidents had lasting effects on their lives. One participant shared, “it’s life-changing…it will stay with me forever. It’s changed my career.” Some participants also experienced long-term impacts, including hypervigilance and avoidance of large crowds and gatherings. For instance, one participant stated, “I used to go to college football games all the time. I don’t think I’ve been to a college football game since.… I don’t want to be in crowds as much as I used to.” Another shared, “I had a very visceral reaction to discussions around it [the incident] for months, if not years. It has had huge effects.”

One participant shared, “it’s life-changing…it will stay with me forever. It’s changed my career.”

Stigma and Help-Seeking

Despite being profoundly impacted, most participants in our study did not seek formal mental health support. While many acknowledged that mental health support was made available to them following these incidents, these services were underutilized. Instead, many physicians preferred to engage in informal peer support, including peer mentorship and gatherings in relaxed settings, such as at the homes of fellow physicians.

Our interviews reflected that reluctance to seek formal mental health support might be due to the stigma physicians often face and the fear that licensing bodies may revoke or restrict their license to practice should a mental health issue be disclosed on a licensing application or renewal. For instance, one participant stated,

I strongly identify as an emergency physician….and that could be taken away from me if when I reapply for my medical licensure, they ask, ‘have you ever had any mental health disorders?’ If I get a diagnosis because I was having issues dealing with an event and I have to disclose that, I’m placing myself in jeopardy of losing my medical license.

Another shared, “if you go and seek help and receive that diagnosis, you will have to notify the [state] medical board. You could be in danger of losing your license, so there is not only a stigma, but there’s negative reinforcement.”

Stigma related to help-seeking is not unique to physicians who treat casualties of mass public shootings, as this issue has been discussed extensively for many years. However, the demand for mental health support and tailored services is likely even greater during and after human-made disasters, such as mass public shootings. Therefore, efforts should be made to alleviate barriers to accessing support to improve overall well-being, decrease burnout, and better equip physicians to respond during these and other trauma-related incidents. Creating a culture of care and taking proactive measures to promote wellness among physicians is imperative, as “an ounce of prevention is worth a pound of cure.”

Overcoming Barriers

Physicians face complex challenges and barriers when attempting to access mental health support. While the disclosure of mental health diagnoses to medical boards was initially intended to safeguard the public from physicians who may be impaired, the Federation of State Medical Boards (FSMB) contends that such disclosure does not reliably predict the risk of harm to patients. Instead, it prevents physicians from receiving necessary mental healthcare, potentially exacerbating impairment. To help mitigate these barriers, the FSMB offered several recommendations, including urging medical boards to “evaluate whether it is necessary to include probing questions about a physician applicant’s mental health, addiction, or substance use” on licensure applications or renewals. More specifically, the FSMB made the following recommendations to be compliant with the Americans with Disabilities Act (ADA): (1) limiting mental health questions to conditions that result in impairment; (2) limiting mental health questions to conditions within the past two years or less; (3) not requiring physicians to disclose their diagnosis or treatment to the board if they are enrolled in a Physician Health Program; and (4) using supportive language about seeking mental health care. However, a recent study found that only 5 percent of medical boards were in compliance with the FSMB’s recommendations.

Access to supportive services is vital, as burnout and poor mental health among physicians have been linked to increased rates of suicide, as well as medical errors and suboptimal patient care. Therefore, to eliminate barriers to help-seeking, state licensing boards might carefully consider revising their policies to align with the recommendations put forth by the FSMB. For example, in 2020, the Texas Medical Board (TMB) revised the language related to mental health in applications for initial medical licenses and renewals. Due to these changes, the TMB is now in full compliance with the FSMB’s guidelines, fostering a more supportive atmosphere and reducing obstacles to mental healthcare. Furthermore, because mental health support is underutilized by physicians, alternative forms of support should be made available to them following mass public shootings. Facilitating opportunities for peer support, for instance, can be a valuable resource, as this can help normalize emotions and reactions to difficult experiences and has been found to increase well-being and reduce mental health stigma among physicians. To enhance support, hospitals might consider organizing formal and informal gatherings for these individuals to come together and begin to process.

Additionally, physicians should be afforded ample space and time to decompress and grieve. In our study, five participants mentioned the challenges of dealing with the media coverage in the immediate aftermath of the incident and how they did not have an opportunity to reflect on or process their emotions before they were required to make a statement to the press, as has been seen in several post-incident news briefings in the past. Due to this, hospitals should allow physicians to decline requests for press interviews and consider designating a hospital spokesperson who is uninvolved in the medical treatment of casualties to handle any media requests.

Community support also plays a crucial role in the recovery process for physicians after mass public shootings. Hospital systems can partner with local and regional healthcare networks to facilitate shift coverage and adequate time off so that these individuals can participate in community memorials and vigils. Attending public rituals can promote community solidarity and cohesion, bolstering resilience in those affected by disasters. Additionally, hospitals should recognize the lasting effects mass public shooting incidents can have on physicians, providing tailored support and adopting a trauma-informed approach and policies across all stages of disaster recovery. Some participants, for example, expressed the desire to give back to their communities and the medical profession and found channeling their grief into action to be an important part of their recovery journey. One participant shared, “I had to figure out how I was going to make something better of this.” However, not all felt supported by their employers in pursuing these endeavors. Hospital systems should acknowledge the diverse ways in which meaning-making and healing occur and support physicians in these activities, as altruism has been found to foster post-traumatic growth.

Physicians are often overlooked following mass public shootings and may ultimately suffer in silence. These medical professionals should be offered equal opportunities to heal alongside others within their communities, as “no one who sees a disaster is untouched by it.” Ultimately, the mental health and well-being of physicians should be prioritized and help-seeking normalized after mass public shooting incidents. Additionally, while this piece highlights the needs of physicians, it is important to acknowledge that other members of the broader healthcare team, like respiratory therapists, hospital technicians, and social workers, are also often overlooked. Therefore, further studies are warranted to understand their experiences after mass public shootings. Ultimately, it is time to heed the call to care for those who selflessly care for us.

ABOUT THE AUTHOR

Rebecca Cowan is a faculty member in the College of Social and Behavioral Health at Walden University and an affiliate scholar with the Regional Gun Violence Research Consortium. As a disaster mental health supervisor with the American Red Cross, she has responded to several mass shootings, including the Route 91 Harvest Festival in Las Vegas, Nevada, Marjory Stoneman Douglas High School in Parkland, Florida, and Robb Elementary School in Uvalde, Texas. Cowan also served as a gubernatorial appointee on the Commission to Investigate the May 31, 2019, Virginia Beach Mass Shooting.

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