Original Research
Annals of Internal Medicine
Internists’ Attitudes Toward Prevention of Firearm Injury Renee Butkus, BA, and Arlene Weissman, PhD
Background: Professional organizations have called for the medical community’s attention to the prevention of firearm injury. However, little is known about physicians’ attitudes and practices in preventing firearm injury. Objective: To determine internists’ attitudes and practices about firearms and to assess whether opinions differ according to whether there are gun owners in a physician’s home. Design: Cross-sectional survey. Setting: Internal medicine practices. Participants: 573 internists representative of American College of Physicians’ members. Measures: Respondents’ experiences and reported practice behaviors related to firearms and their opinions about contributors and public policies related to firearm violence, as well as physician education and training in firearm safety. Results: The survey response rate was 56.5%. Eighty-five percent of respondents believed that firearm injury is a public health issue,
T
he rate of firearm-related deaths in the United States is the highest among industrialized countries (1). More than 32 000 persons are killed in the United States by firearms each year, including homicides, suicides, and accidental deaths, and amounts to 85 deaths per day. Firearms are the second-leading cause of death due to injury after motor vehicle crashes (2). Firearm homicides result in 11 000 deaths each year (3), and more than 19 000 deaths by firearms are suicides (4). Several mass shootings in the United States, including the fatal shooting of 20 children and 6 adults at Sandy Hook Elementary School in Newtown, Connecticut, have brought firearm violence to the forefront of national discussion. In 1996, the American College of Physicians (ACP) surveyed its membership about attitudes and practices of physicians related to firearms (5). Ninety-four percent of responding internists believed that firearm violence was a major public health issue, and 84% supported enacting legislation to restrict the possession or sale of handguns. Further, whereas 84% favored physician involvement in preventing firearm injury, only 15% reported providing counseling about injury prevention that included firearm ownership and storage. At the time, several medical organizations had called for increased attention from the medical community on the prevention of firearm injury (6, 7). ACP urged its members to get actively involved in efforts to prevent firearm injury within the medical field and in the larger community, inquire and counsel patients about firearm safety measures, obtain training related to the prevention of firearm injury, and support efforts to enact legislation to regulate the sale of legal firearms (5). After more
and 71% believed that it is a bigger problem today than a decade ago. Seventy-six percent of respondents believed that stricter gun control legislation would help reduce the risks for gun-related injuries or deaths. Although 66% of respondents believed that physicians should have the right to counsel patients on preventing deaths and injuries from firearms, 58% reported never asking whether patients have guns in their homes. Limitations: The generalizability of these findings to non–American College of Physicians’ member internists and other physicians is unknown. Responses may not reflect actual behavior. Conclusion: Most respondents believed that firearm-related violence is a public health issue and favored policy initiatives aimed at reducing it. Although most internists supported a physician’s right to counsel patients about gun safety, few reported currently doing it. Primary Funding Source: None. Ann Intern Med. 2014;160:821-827. www.annals.org For author affiliations, see end of text. This article was published online first at www.annals.org on 10 April 2014.
recent tragedies, ACP reaffirmed its call for such legislation (8) and continues to advocate for measures to reduce firearm violence (9). Journal editors also urged their fellow physicians to speak out on firearm violence as a public health issue (10). As these conversations continue, it is important to understand physician attitudes about various policies and practices to prevent firearm injury. Physicians witness firsthand the devastating consequences of firearm violence to victims and their families. These unnecessary injuries and deaths affect their patients, families, and communities. Physicians can play an important role in intervening with patients who risk injuring themselves or others through the use of firearms (11, 12). We surveyed ACP members to better understand current attitudes toward firearms and firearm injury and compared these data to findings from the 1996 survey. We further wondered whether opinions among physicians vary according to whether there were gun owners in their homes.
See also: Related article. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 858 Web-Only Supplement © 2014 American College of Physicians 821
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Original Research
Internists’ Attitudes Toward Prevention of Firearm Injury
Context Recent events have prompted calls for medical community involvement in efforts to reduce firearm-related violence. Physicians’ attitudes about potential efforts at reducing firearm violence are not well-understood.
Data Synthesis and Analysis
Contribution This survey found that most internists believed that firearm-related violence is a public health issue and that physicians should have the right to discuss firearm safety with patients, although few reported doing so. Most respondents reported favoring various public policies aimed at reducing firearm-related violence.
Limitation The study included only internists, and it could not evaluate actual practice.
Implication Physician support may be useful in efforts to reduce firearm-related violence. —The Editors
METHODS Study Sample
We did a cross-sectional survey among a large, nationally representative panel of ACP nonstudent members in the United States. The Internal Medicine Insider Research Panel, which was initiated in June 2011, is an exclusive community of U.S. ACP members (both in training and practicing) who participate in research surveys distributed by the ACP Research Center. One percent of ACP members (including trainees) are invited to participate in the panel via stratified random sampling to ensure that the panel is representative of ACP membership within the United States across multiple demographic characteristics. Panel members who complete surveys were awarded points that may be redeemed for gift cards. Questionnaire Design and Data Collection
The survey was developed by ACP staff from 2 divisions: Government Affairs and Public Policy and the Research Center. The 1996 survey of ACP members on physician attitudes toward firearms and the prevention of firearm injury was used to guide development of the initial questions that were then expanded to include current options being considered by policymakers as ways to reduce firearm violence. All authors reviewed, tested, and edited multiple iterations of the survey for understandability. The final survey is available in the Supplement (available at www.annals.org). Survey questions were designed to gather physician input on their beliefs about contributors of firearm violence, their attitudes toward public policies on the prevention of firearm injury, their overall experiences with fire822 17 June 2014 Annals of Internal Medicine Volume 160 • Number 12
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arms, factors affecting their clinical practice behaviors, and the perceived need for education and training. The final version of the instrument was e-mailed to 1014 panel members on 12 February 2013 and remained in the field for 8 days. Data were analyzed using descriptive statistics. Statistical analyses were done using SPSS Statistics, version 21 (IBM, Armonk, New York), and StatPac (StatPac, Bloomington, Minnesota). Role of the Funding Source
No external funding was obtained for this survey.
RESULTS Demographic Characteristics
Table 1 summarizes demographic characteristics for the 573 survey responders (56.5% response rate). Responders did not differ substantially from the 441 persons who did not respond on any of the demographic characteristics collected during panel registration (not shown). By design, respondents were representative of ACP’s U.S. membership. Most respondents were men (70%), were white (57%), and specialized in general internal medicine (63%). In addition, they were fairly evenly divided across 3 age groups and represented the 4 regions of the country. Ninety-five percent of respondents reported involvement in patient care, with most of them providing these services in an office-based practice (35%) or in an academic medical center or a medical school (27%). Sixtyfour percent of them reported having had patients who were injured or killed by a gun. Fourteen percent of respondents reported that they or someone in their family was threatened or injured by someone with a gun. As shown in Table 1, 21% of respondents reported that they or someone else in their home owned a gun. These respondents tended to be older, more often white, from the South, and delivering care in an office-based practice. Recreational reasons were the most commonly reported reason for gun ownership: target shooting (57%), hunting (30%), and part of a gun collection (28%). Fortyfour percent reported keeping a gun for protection. Opinions About a U.S. Plan to Prevent Firearm Violence
Fifty-one percent of respondents believed that the United States agreeing on a plan to prevent firearm violence is extremely important (Table 2). Persons most likely to personally believe that it is extremely important tend to be older than 55 years (55%), women (56%), nonwhite (59%), from the Northeast (60%), and from homes where there was no gun owner (56%). Attitudes Toward Prevention of Firearm Injury
To prevent gun-related injury and death, 76% of respondents believed that controlling gun ownership is more important than protecting the right to own guns. Furthermore, most respondents (59%) reported being at least www.annals.org
Internists’ Attitudes Toward Prevention of Firearm Injury
somewhat worried that a mass shooting could happen in their community. Eighty-five percent of respondents strongly or somewhat agreed that firearm injury is a public health issue, and 71% believed that gun violence is a bigger problem today than it was a decade ago. However, as shown in Figure 1, respondents from homes without a gun owner more often agreed somewhat or strongly that gun violence is a bigger problem today than did those from homes with a gun owner (75% vs. 57%). Sixty-eight percent of respondents without a gun owner in the home and 57% of those with a gun owner in the home agreed somewhat or strongly that it is appropriate for physicians to counsel patients about gun safety. Fifty-six percent of respondents from homes without gun owners and 47% from homes with gun owners agreed somewhat or strongly that physicians should be involved in the prevention of firearm injury and 52% and 43%, respectively, agree somewhat or strongly that physicians should obtain training on the prevention of firearm injury. Although 55% of respondents believed that inadequate treatment of persons with mental illness contributes a great deal to gun violence in America, only 22% believed that better mental health screening and treatment would help reduce gun violence a great deal; 49% of respondents believed that it would help somewhat and 23% not much or not at all. Public Policies on Firearms
Ninety-five percent of respondents reported favoring mandatory background checks on all gun purchases regardless of whether through an authorized dealer, gun show, or other private sale. Eighty-seven percent of them favored banning armor-piercing bullets (Appendix Table 1, available at www.annals.org). Ninety-seven percent of respondents favored improving access to mental health services, and 85% favored preventing persons with mental illness from purchasing guns. As shown in Figure 2, differences in responses were noted between physicians with and without gun owners in the home. Respondents without gun owners in the home more often reported favoring policies mandating registration of all guns, including handguns, rifles, shotguns, and semiautomatic weapons (89% vs. 50%); banning the possession of assault weapons except by the military and other authorized persons (92% vs. 63%); requiring safety features to make guns more child-proof (91% vs. 67%); banning sales of firearms to persons younger than 21 years (88% vs. 63%); and creating a federal database to track gun sales (84% vs. 60%). Role of Internists in Reducing Firearm Violence
Fifty-eight of respondents who reported seeing patients reported never discussing with their patients whether there were guns in the home, and 80% never discuss whether the patient used guns. Seventy-seven percent of respondents reported never discussing ways to reduce the www.annals.org
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Original Research
Table 1. Characteristics of Survey Respondents* Respondents, %
Characteristic Total (n ⴝ 573)
Gun Owner in Home (n ⴝ 121)
No Gun Owner in Home (n ⴝ 452)
Age group ⱕ39 y 40–55 y ⬎55 y
34 35 31
24 32 44
37 36 28
Sex Male Female
70 30
75 25
69 31
Specialty General internal medicine Internal medicine subspecialty
63 37
65 35
62 38
Race White Nonwhite Not specified
57 33 10
76 14 10
51 38 10
Region of country Midwest Northeast South West
23 26 30 21
19 12 44 25
24 30 26 20
Physician status In training Practicing
21 79
14 86
23 77
Practice setting Office-based practice Academic medical center/ medical school Hospital Government facility Community health center/clinic Retired Other
35 27
44 23
33 27
16 10 5 3 4
12 7 3 5 6
17 11 6 2 4
Time spent in direct patient care Yes No
95 5
93 7
95 5
Had a patient injured/killed by a gun Yes No
64 36
61 39
65 35
Respondent/family member threatened/injured by someone with a gun Yes No
14 86
15 85
14 86
* Percentages may not sum to 100 due to rounding.
risk for gun-related injury or death, and 62% reported never discussing the importance of keeping guns away from children (Appendix Table 2, available at www.annals .org). Most respondents (77%) are very or somewhat comfortable in reporting a patient who threatened to harm himself or herself or others. When asked the extent to which there was a need for an educational program de17 June 2014 Annals of Internal Medicine Volume 160 • Number 12 823
Original Research
Internists’ Attitudes Toward Prevention of Firearm Injury
Table 2. Importance of a U.S. Plan to Prevent Firearm Violence, by Demographic Characteristics* Importance of a Plan to Prevent Firearm Violence, %
Characteristic Extremely Important (n ⴝ 291)
Very Important (n ⴝ 156)
Moderately Important (n ⴝ 82)
Not Too Important (n ⴝ 24)
Not at All Important (n ⴝ 15)
Not Sure (n ⴝ 5)
Total respondents
51
27
14
4
3
1
Age group ⱕ39 y 40–55 y ⬎55 y
49 50 55
31 28 23
16 13 14
3 5 6
1 5 2
1 1 1
Sex Male Female
49 56
27 26
15 14
4 3
3 1
1 0
Race White Nonwhite Not specified
48 59 42
25 27 39
17 10 12
6 2 5
3 2 2
1 1 0
Region of country Midwest Northeast South West
50 60 43 51
30 26 26 27
11 9 18 18
4 3 7 3
3 1 5 1
2 1 1 0
Physician status In training Practicing
45 52
34 26
15 14
4 4
2 3
1 1
Specialty General internal medicine Internal medicine subspecialty
49 55
30 22
13 17
4 4
3 2
1 0
Practice setting Office-based practice Academic medical center/medical school Hospital Government facility Community health center/clinic Retired Other
51 51 52 50 39 47 63
21 30 26 36 45 35 17
19 13 12 11 6 12 13
3 5 7 0 6 6 4
5 1 3 2 0 0 0
1 0 0 2 3 0 4
Gun owner in home Yes No
33 56
23 28
26 11
7 3
8 1
3 1
Time spent in direct patient care Yes No
50 61
27 26
15 7
4 0
3 3
1 3
* Percentages may not sum to 100 due to rounding.
signed to increase the knowledge and skills of physicians in how to counsel patients in the prevention of firearm injury, 74% of respondents replied “somewhat/to a great extent” (Appendix Table 3, available at www.annals.org). In addition, 66% of respondents would be very or somewhat interested in participating in an educational program to help them counsel their patients on the prevention of firearm injury. Non– gun owners more often reported interest in such a program than did those from a home with gun owners (69% vs. 58%). Twelve percent of respondents believed that ACP should make reducing gun violence in this country its 824 17 June 2014 Annals of Internal Medicine Volume 160 • Number 12
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highest priority, and an additional 51% believed that it should be a high priority but not its highest. This compares with one third of all respondents who believed that ACP should give reducing gun violence a lower priority (25%) or no priority (8%).
DISCUSSION Most internists who responded to our survey believed that firearm-related violence is a public health issue. In addition, most respondents favored policy initiatives aimed at reducing the problem. Most responding internists bewww.annals.org
Internists’ Attitudes Toward Prevention of Firearm Injury
Original Research
ive of certain policies than the general public. More than 80% of the internists included in the current survey supported banning the possession of assault weapons except by military and other authorized persons and banning highcapacity magazines, whereas only slightly more than one half of the general public reported supporting such measures in the Pew Research Center study (13). Although it is not possible to draw confident conclusions comparing the populations surveyed, it does seem, on the basis of these findings, that support for changes in policy aimed at gun violence is greater among physicians than the U.S. population in general. Although most respondents in our study believed that it is appropriate for physicians to counsel patients on gun safety, most reported not asking their patients about gun ownership or gun safety. Respondents with a gun owner in the home more often reported asking their patients about gun use than did those without a gun owner in the home.
lieved that physicians should have the right to counsel their patients about firearm-related violence. Despite that, few internists reported currently engaging in such patient counseling. These data may be useful in the development of policy initiatives and educational resources. These data are consistent with results from the 1996 study of internists, as well as a recent survey of the U.S. general population. Our survey in 1996 found that 94% of internists viewed firearm violence as a public health issue and 84% believed that stricter gun regulation would help to reduce gun injury or death. A national public survey conducted in January 2013 by the Pew Research Center found strong support (95% of respondents) for mandatory background checks on all gun purchases and preventing persons with mental illness from purchasing guns (80%). Although each of these surveys found that most respondents supported policies to regulate firearms, the physicians who responded to our survey seemed to be more support-
Figure 1. Attitudes of respondents toward firearm injury and prevention. 80% 60%
Firearm injury is a public health issue
40% 20%
61
49
26
28
8
10
4
2
1
10
1
1
37
27
21
27
15
7
6
16
2
3
27
27
30
12
11
7
17
1
12
5
3
31
32
26
17
15
8
12
6
15
1
1
26
24
23
6
6
6
14
4
27
1
3
29
39
39
37
11
8
4
3
2
5
7
18
18
34
25
28
13
13
14
3
2
0% 80%
Physicians should be involved in prevention 60% 40% of firearm injury 20%
19
0%
Gun violence is a bigger problem than it was a decade ago
It is appropriate for physicians to counsel patients about gun control
80% 60% 40% 20% 0%
48
80% 60% 40% 20% 0%
Stricter gun control legislation will help to reduce risks for gun-related injury or death
80% 60% 40% 20% 0%
Increased government spending on mental health screening and treatment would help to reduce the risks for gunrelated injury or death
80% 60% 40% 20% 0%
36
58
20
16
80% 60%
No Gun Owner in Home (n = 452)
ot S
St
ro n
gl y
N
D
isa
isa
gr ee
gr ee
8
tD ha
24
ew
ha t ew m So
St
ro n
gl y
Ag r
Ag re e
ee
0%
So m
20%
ur e
40%
N ei no the rD rA isa gre gr e ee
Physicians should obtain training on prevention of firearm injury
Gun Owner in Home (n = 121)
The y-axis shows the percentage of respondents with opinions about each category. www.annals.org
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17 June 2014 Annals of Internal Medicine Volume 160 • Number 12 825
Original Research
Internists’ Attitudes Toward Prevention of Firearm Injury
Figure 2. Percentage favoring various firearm-related initiatives. Mandatory background check on all gun purchases regardless of whether through an authorized dealer, gun show, or other private sale Mandatory registration of all guns, including handguns, rifles, shotguns, and semiautomatic weapons Mandatory safety training before buying a gun
Banning the possession of assault weapons except by the military and other authorized persons Banning the possession of high-capacity magazines except by the military and other authorized persons Banning armor-piercing bullets
Preventing persons with mental illness from purchasing guns Preserving the rights of physicians to counsel their patients on preventing deaths and injuries from firearms Improving access to mental health services
Requiring safety features to make guns more child-proof
Banning sale of firearms to persons younger than 21 y
Creating a federal database to track gun sales 0
20
40
60
80
100
Favoring Measure, % No Gun Owner in Home (n = 452)
This may be due to greater familiarity with guns and appropriate safety measures. The lack of training on the issue could be a barrier for non– gun owners. Most responding internists believed that there is a need for an educational program to increase the knowledge and skills of physicians in how to counsel their patients. This is an important message for medical schools, residency programs, and organizations that provide continuing medical education. It is also promising because the evidence already supports the important role that physicians can play in the prevention of firearm injury. Patients and families of those who risk firearm injury have indicated a willingness to discuss concerns and safety options with their physicians (11). Counseling efforts by physicians have been shown to make a positive effect in the firearm storage habits of their patients (12, 14). Not only is it important for physicians to become properly educated about the risks 826 17 June 2014 Annals of Internal Medicine Volume 160 • Number 12
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Gun Owner in Home (n = 121)
of firearm ownership and the need for safety measures, but it is also essential that they be taught how to communicate this to their patients through proper screening, counseling, and education. A greater understanding of risk factors for suicide and identification of persons who are at risk for harming themselves or others is also important. Our study had several notable strengths and limitations. We surveyed a well-characterized, nationally representative cohort of internists. Despite a 56.5% response rate, there were no obvious differences between persons who did or did not respond (differences would suggest the risk of participation bias), although we cannot definitively exclude the possibility of bias. Our data reflect physicians’ reported attitudes but cannot assess their actual behavior in practice. Because the survey was conducted soon after a mass shooting in Newtown, Connecticut, which involved the murder of school children, the lingering emotional www.annals.org
Internists’ Attitudes Toward Prevention of Firearm Injury
effect of this event may have influenced respondents’ attitudes about preventing firearm injury. In addition, we surveyed only physicians trained in internal medicine, although our respondents reflect a wide array of generalists and subspecialists. Future research should evaluate the reasons why physicians do not currently ask patients about the presence of guns in their environment or measures to promote firearm safety. Although we found that 80% of physicians did not ask such questions, we did not ask why. Data on the types of educational programs or materials related to firearm safety that physicians believe would be beneficial and in which they would participate may also be useful as medical schools and professional organizations aim to enhance educational efforts at reducing the public health threats of firearm violence. Patients have long trusted their physicians to advise them on issues affecting their health. Firearm violence is a public health problem in which physicians may play a critical role. Our survey suggests that most internists would support initiatives that would engage physicians in efforts to prevent gun-related violence from harming their patients and communities. Greater emphasis on understanding the types of programs that would provide the greatest benefit and how to implement them is warranted. From the American College of Physicians, Washington, DC, and Philadelphia, Pennsylvania. Disclosures: Authors have disclosed no conflicts of interest. Forms can
be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms .do?msNum⫽M13-1960. Reproducible Research Statement: Study protocol, statistical code, and
data set: Available from Dr. Weissman (e-mail, aweissman@acponline .org). Requests for Single Reprints: Renee Butkus, BA, American College of Physicians, 25 Massachusetts Avenue NW, Washington, DC 20001; e-mail, [email protected].
Current author addresses and author contributions are available at www.annals.org.
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Original Research
References 1. Richardson EG, Hemenway D. Homicide, suicide, and unintentional firearm fatality: comparing the United States with other high-income countries, 2003. J Trauma. 2011;70:238-43. [PMID: 20571454] 2. Centers for Disease Control and Prevention. Injury Prevention & Control: Data & Statistics (WISQARS). Atlanta, GA: Centers for Disease Control and Prevention; 2014. Accessed at www.cdc.gov/ncipc/wisqars on 12 May 2013. 3. Hoyert DL, Xu J. Deaths: Preliminary Data for 2011. National Vital Statistics Reports. Hyattsville, MD: U.S. Department of Health and Human Services; 2012;61:1-65. 4. Centers for Disease Control and Prevention. FastStats. Suicide and SelfInflicted Injury. Atlanta, GA: Centers for Disease Control and Prevention; 2013. Accessed at www.cdc.gov/nchs/fastats/suicide.htm on 12 May 2013. 5. Cassel CK, Nelson EA, Smith TW, Schwab CW, Barlow B, Gary NE. Internists’ and surgeons’ attitudes toward guns and firearm injury prevention. Ann Intern Med. 1998;128:224-30. [PMID: 9454531] 6. American Academy of Orthopaedic Surgeons. July 1996 Bulletin. Position Statement: Firearms Violence. Rosemont, IL: American Acad of Orthopaedic Surgeons; 1996. Accessed at www2.aaos.org/bulletin/jul96/position.htm on 29 January 2014. 7. American Public Health Association. Policy Statement: Handgun Injury Reduction. Washington, DC: American Public Health Assoc; 1 January 1998. Accessed at www.apha.org/advocacy/policy/policysearch/default.htm?id⫽170 on 29 January 2014. 8. Bronson DL. Statement of the ACP: Reducing Firearms-Related Deaths and Injuries. Philadelphia: American Coll of Physicians. 20 December 2012. Accessed at www.acponline.org/acp_policy/policies/reducing_firearms-related_deaths_and _injuries_2012.pdf on 19 June 2013. 9. Bronson DL. Letter to Sen. Harry Reid supporting legislation to reduce firearms-related deaths and injuries. Philadelphia: American Coll of Physicians; 5 April 2013. Accessed at www.acponline.org/acp_policy/letters/reid_legislation _to_reduce_firearms_injuries_2013.pdf on 19 June 2013. 10. Laine C, Taichman DB, Mulrow C, Berkwits M, Cotton D, Williams SV. A resolution for physicians: time to focus on the public health threat of gun violence [Editorial]. Ann Intern Med. 2013;158:493-4. [PMID: 23277894] 11. Gardner W, Klima J, Chisolm D, Feehan H, Bridge J, Campo J, et al. Screening, triage, and referral of patients who report suicidal thought during a primary care visit. Pediatrics. 2010;125:945-52. [PMID: 20385642] 12. Albright TL, Burge SK. Improving firearm storage habits: impact of brief office counseling by family physicians. J Am Board Fam Pract. 2003;16:40-6. [PMID: 12583649] 13. Pew Research Center for the People and the Press. In Gun Control Debate, Several Options Draw Majority Support. Washington, DC: Pew Research Center for the People and the Press; 2013. Accessed at www.people-press.org/2013/01/ 14/in-gun-control-debate-several-options-draw-majority-support on 19 June 2013. 14. Carbone PS, Clemens CJ, Ball TM. Effectiveness of gun-safety counseling and a gun lock giveaway in a Hispanic community. Arch Pediatr Adolesc Med. 2005;159:1049-54. [PMID: 16275796]
17 June 2014 Annals of Internal Medicine Volume 160 • Number 12 827
Annals of Internal Medicine Current Author Addresses: Ms. Butkus: American College of Physicians, 25 Massachusetts Avenue NW, Washington, DC 20001. Dr. Weissman: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
Author Contributions: Conception and design: R. Butkus, A.
Weissman. Analysis and interpretation of the data: R. Butkus, A. Weissman. Drafting of the article: R. Butkus, A. Weissman. Critical revision of the article for important intellectual content: R. Butkus. Final approval of the article: R. Butkus, A. Weissman. Administrative, technical, or logistic support: R. Butkus. Collection and assembly of data: A. Weissman.
Appendix Table 1. Support by Internists for Specific Measures to Deal With Firearm Violence Respondents Who Favor Measure, %
Measure
Mandatory background check on all gun purchases regardless of whether through an authorized dealer, gun show, or other private sale Mandatory registration of all guns, including handguns, rifles, shotguns, and semiautomatic weapons Mandatory safety training before buying a gun Banning the possession of assault weapons except by the military and other authorized persons Banning the possession of high-capacity magazines except by the military and other authorized persons Banning armor-piercing bullets Preventing persons with mental illness from purchasing guns Preserving the rights of physicians to counsel their patients on preventing deaths and injuries from firearms Improving access to mental health services Requiring safety features to make guns more child-proof Banning sale of firearms to persons younger than 21 y Creating a federal database to track gun sales
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Total (n ⴝ 573)
Gun Owner in Home (n ⴝ 121)
No Gun Owner in Home (n ⴝ 452)
95
88
97
81
50
89
88 86
74 63
91 92
85
68
89
87 85 86
79 85 84
89 85 86
97 86 83 79
98 67 63 60
96 91 88 84
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Appendix Table 2. Frequency of Discussions About Gun-Related Issues Frequency of Discussion, %*
Issue Total Respondents (n ⴝ 542)†
Respondents With Gun Owner in Home (n ⴝ 112)
Respondents Without Gun Owner in Home (n ⴝ 430)
Whether the patient has guns in his/her home Always Sometimes Never
3 39 58
5 48 46
3 37 60
Whether the patient uses guns even if a gun is not present in the home Always Sometimes Never
1 19 80
1 23 76
1 18 81
Ways to reduce the risk for gun-related injury or death Always Sometimes Never
2 21 77
2 28 71
2 19 79
Importance of keeping guns in the home away from children Always Sometimes Never
6 32 62
12 39 49
5 30 65
Voluntarily removing the gun from the home Always Sometimes Never
1 22 77
1 31 68
1 20 79
* Percentages may not sum to 100 due to rounding. † Respondents who reported time spent in direct patient care.
Appendix Table 3. Interest in Education Interest in Education, %
Issue Total Respondents (n ⴝ 542)*
Respondents With Gun Owner in Home (n ⴝ 112)
Respondents Without Gun Owner in Home (n ⴝ 430)
Comfort in reporting a patient who threatens to harm himself/herself or others to the background-check system Very comfortable Somewhat comfortable Not comfortable Not sure
40 37 13 10
52 26 14 8
36 40 13 11
Agree with the need for an educational program designed to increase the knowledge and skills of physicians in how to counsel patients in the prevention of firearm injury To a great extent Somewhat Not too much Not at all Not sure
30 44 14 8 4
24 38 20 15 3
32 45 13 6 4
Interest in participating in an educational program on how to counsel patients in the prevention of firearm injury Very interested Somewhat interested Not too interested Not at all interested Not sure
23 43 20 11 3
22 36 22 20 0
24 45 19 9 3
* Respondents who reported time spent in direct patient care. 17 June 2014 Annals of Internal Medicine Volume 160 • Number 12
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Annals of Internal Medicine
Internists’ Attitudes Toward Prevention of Firearm Injury Renee Butkus, BA, and Arlene Weissman, PhD
Background: Professional organizations have called for the medical community’s attention to the prevention of firearm injury. However, little is known about physicians’ attitudes and practices in preventing firearm injury. Objective: To determine internists’ attitudes and practices about firearms and to assess whether opinions differ according to whether there are gun owners in a physician’s home. Design: Cross-sectional survey. Setting: Internal medicine practices. Participants: 573 internists representative of American College of Physicians’ members. Measures: Respondents’ experiences and reported practice behaviors related to firearms and their opinions about contributors and public policies related to firearm violence, as well as physician education and training in firearm safety. Results: The survey response rate was 56.5%. Eighty-five percent of respondents believed that firearm injury is a public health issue,
T
he rate of firearm-related deaths in the United States is the highest among industrialized countries (1). More than 32 000 persons are killed in the United States by firearms each year, including homicides, suicides, and accidental deaths, and amounts to 85 deaths per day. Firearms are the second-leading cause of death due to injury after motor vehicle crashes (2). Firearm homicides result in 11 000 deaths each year (3), and more than 19 000 deaths by firearms are suicides (4). Several mass shootings in the United States, including the fatal shooting of 20 children and 6 adults at Sandy Hook Elementary School in Newtown, Connecticut, have brought firearm violence to the forefront of national discussion. In 1996, the American College of Physicians (ACP) surveyed its membership about attitudes and practices of physicians related to firearms (5). Ninety-four percent of responding internists believed that firearm violence was a major public health issue, and 84% supported enacting legislation to restrict the possession or sale of handguns. Further, whereas 84% favored physician involvement in preventing firearm injury, only 15% reported providing counseling about injury prevention that included firearm ownership and storage. At the time, several medical organizations had called for increased attention from the medical community on the prevention of firearm injury (6, 7). ACP urged its members to get actively involved in efforts to prevent firearm injury within the medical field and in the larger community, inquire and counsel patients about firearm safety measures, obtain training related to the prevention of firearm injury, and support efforts to enact legislation to regulate the sale of legal firearms (5). After more
and 71% believed that it is a bigger problem today than a decade ago. Seventy-six percent of respondents believed that stricter gun control legislation would help reduce the risks for gun-related injuries or deaths. Although 66% of respondents believed that physicians should have the right to counsel patients on preventing deaths and injuries from firearms, 58% reported never asking whether patients have guns in their homes. Limitations: The generalizability of these findings to non–American College of Physicians’ member internists and other physicians is unknown. Responses may not reflect actual behavior. Conclusion: Most respondents believed that firearm-related violence is a public health issue and favored policy initiatives aimed at reducing it. Although most internists supported a physician’s right to counsel patients about gun safety, few reported currently doing it. Primary Funding Source: None. Ann Intern Med. 2014;160:821-827. www.annals.org For author affiliations, see end of text. This article was published online first at www.annals.org on 10 April 2014.
recent tragedies, ACP reaffirmed its call for such legislation (8) and continues to advocate for measures to reduce firearm violence (9). Journal editors also urged their fellow physicians to speak out on firearm violence as a public health issue (10). As these conversations continue, it is important to understand physician attitudes about various policies and practices to prevent firearm injury. Physicians witness firsthand the devastating consequences of firearm violence to victims and their families. These unnecessary injuries and deaths affect their patients, families, and communities. Physicians can play an important role in intervening with patients who risk injuring themselves or others through the use of firearms (11, 12). We surveyed ACP members to better understand current attitudes toward firearms and firearm injury and compared these data to findings from the 1996 survey. We further wondered whether opinions among physicians vary according to whether there were gun owners in their homes.
See also: Related article. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 858 Web-Only Supplement © 2014 American College of Physicians 821
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Original Research
Internists’ Attitudes Toward Prevention of Firearm Injury
Context Recent events have prompted calls for medical community involvement in efforts to reduce firearm-related violence. Physicians’ attitudes about potential efforts at reducing firearm violence are not well-understood.
Data Synthesis and Analysis
Contribution This survey found that most internists believed that firearm-related violence is a public health issue and that physicians should have the right to discuss firearm safety with patients, although few reported doing so. Most respondents reported favoring various public policies aimed at reducing firearm-related violence.
Limitation The study included only internists, and it could not evaluate actual practice.
Implication Physician support may be useful in efforts to reduce firearm-related violence. —The Editors
METHODS Study Sample
We did a cross-sectional survey among a large, nationally representative panel of ACP nonstudent members in the United States. The Internal Medicine Insider Research Panel, which was initiated in June 2011, is an exclusive community of U.S. ACP members (both in training and practicing) who participate in research surveys distributed by the ACP Research Center. One percent of ACP members (including trainees) are invited to participate in the panel via stratified random sampling to ensure that the panel is representative of ACP membership within the United States across multiple demographic characteristics. Panel members who complete surveys were awarded points that may be redeemed for gift cards. Questionnaire Design and Data Collection
The survey was developed by ACP staff from 2 divisions: Government Affairs and Public Policy and the Research Center. The 1996 survey of ACP members on physician attitudes toward firearms and the prevention of firearm injury was used to guide development of the initial questions that were then expanded to include current options being considered by policymakers as ways to reduce firearm violence. All authors reviewed, tested, and edited multiple iterations of the survey for understandability. The final survey is available in the Supplement (available at www.annals.org). Survey questions were designed to gather physician input on their beliefs about contributors of firearm violence, their attitudes toward public policies on the prevention of firearm injury, their overall experiences with fire822 17 June 2014 Annals of Internal Medicine Volume 160 • Number 12
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arms, factors affecting their clinical practice behaviors, and the perceived need for education and training. The final version of the instrument was e-mailed to 1014 panel members on 12 February 2013 and remained in the field for 8 days. Data were analyzed using descriptive statistics. Statistical analyses were done using SPSS Statistics, version 21 (IBM, Armonk, New York), and StatPac (StatPac, Bloomington, Minnesota). Role of the Funding Source
No external funding was obtained for this survey.
RESULTS Demographic Characteristics
Table 1 summarizes demographic characteristics for the 573 survey responders (56.5% response rate). Responders did not differ substantially from the 441 persons who did not respond on any of the demographic characteristics collected during panel registration (not shown). By design, respondents were representative of ACP’s U.S. membership. Most respondents were men (70%), were white (57%), and specialized in general internal medicine (63%). In addition, they were fairly evenly divided across 3 age groups and represented the 4 regions of the country. Ninety-five percent of respondents reported involvement in patient care, with most of them providing these services in an office-based practice (35%) or in an academic medical center or a medical school (27%). Sixtyfour percent of them reported having had patients who were injured or killed by a gun. Fourteen percent of respondents reported that they or someone in their family was threatened or injured by someone with a gun. As shown in Table 1, 21% of respondents reported that they or someone else in their home owned a gun. These respondents tended to be older, more often white, from the South, and delivering care in an office-based practice. Recreational reasons were the most commonly reported reason for gun ownership: target shooting (57%), hunting (30%), and part of a gun collection (28%). Fortyfour percent reported keeping a gun for protection. Opinions About a U.S. Plan to Prevent Firearm Violence
Fifty-one percent of respondents believed that the United States agreeing on a plan to prevent firearm violence is extremely important (Table 2). Persons most likely to personally believe that it is extremely important tend to be older than 55 years (55%), women (56%), nonwhite (59%), from the Northeast (60%), and from homes where there was no gun owner (56%). Attitudes Toward Prevention of Firearm Injury
To prevent gun-related injury and death, 76% of respondents believed that controlling gun ownership is more important than protecting the right to own guns. Furthermore, most respondents (59%) reported being at least www.annals.org
Internists’ Attitudes Toward Prevention of Firearm Injury
somewhat worried that a mass shooting could happen in their community. Eighty-five percent of respondents strongly or somewhat agreed that firearm injury is a public health issue, and 71% believed that gun violence is a bigger problem today than it was a decade ago. However, as shown in Figure 1, respondents from homes without a gun owner more often agreed somewhat or strongly that gun violence is a bigger problem today than did those from homes with a gun owner (75% vs. 57%). Sixty-eight percent of respondents without a gun owner in the home and 57% of those with a gun owner in the home agreed somewhat or strongly that it is appropriate for physicians to counsel patients about gun safety. Fifty-six percent of respondents from homes without gun owners and 47% from homes with gun owners agreed somewhat or strongly that physicians should be involved in the prevention of firearm injury and 52% and 43%, respectively, agree somewhat or strongly that physicians should obtain training on the prevention of firearm injury. Although 55% of respondents believed that inadequate treatment of persons with mental illness contributes a great deal to gun violence in America, only 22% believed that better mental health screening and treatment would help reduce gun violence a great deal; 49% of respondents believed that it would help somewhat and 23% not much or not at all. Public Policies on Firearms
Ninety-five percent of respondents reported favoring mandatory background checks on all gun purchases regardless of whether through an authorized dealer, gun show, or other private sale. Eighty-seven percent of them favored banning armor-piercing bullets (Appendix Table 1, available at www.annals.org). Ninety-seven percent of respondents favored improving access to mental health services, and 85% favored preventing persons with mental illness from purchasing guns. As shown in Figure 2, differences in responses were noted between physicians with and without gun owners in the home. Respondents without gun owners in the home more often reported favoring policies mandating registration of all guns, including handguns, rifles, shotguns, and semiautomatic weapons (89% vs. 50%); banning the possession of assault weapons except by the military and other authorized persons (92% vs. 63%); requiring safety features to make guns more child-proof (91% vs. 67%); banning sales of firearms to persons younger than 21 years (88% vs. 63%); and creating a federal database to track gun sales (84% vs. 60%). Role of Internists in Reducing Firearm Violence
Fifty-eight of respondents who reported seeing patients reported never discussing with their patients whether there were guns in the home, and 80% never discuss whether the patient used guns. Seventy-seven percent of respondents reported never discussing ways to reduce the www.annals.org
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Original Research
Table 1. Characteristics of Survey Respondents* Respondents, %
Characteristic Total (n ⴝ 573)
Gun Owner in Home (n ⴝ 121)
No Gun Owner in Home (n ⴝ 452)
Age group ⱕ39 y 40–55 y ⬎55 y
34 35 31
24 32 44
37 36 28
Sex Male Female
70 30
75 25
69 31
Specialty General internal medicine Internal medicine subspecialty
63 37
65 35
62 38
Race White Nonwhite Not specified
57 33 10
76 14 10
51 38 10
Region of country Midwest Northeast South West
23 26 30 21
19 12 44 25
24 30 26 20
Physician status In training Practicing
21 79
14 86
23 77
Practice setting Office-based practice Academic medical center/ medical school Hospital Government facility Community health center/clinic Retired Other
35 27
44 23
33 27
16 10 5 3 4
12 7 3 5 6
17 11 6 2 4
Time spent in direct patient care Yes No
95 5
93 7
95 5
Had a patient injured/killed by a gun Yes No
64 36
61 39
65 35
Respondent/family member threatened/injured by someone with a gun Yes No
14 86
15 85
14 86
* Percentages may not sum to 100 due to rounding.
risk for gun-related injury or death, and 62% reported never discussing the importance of keeping guns away from children (Appendix Table 2, available at www.annals .org). Most respondents (77%) are very or somewhat comfortable in reporting a patient who threatened to harm himself or herself or others. When asked the extent to which there was a need for an educational program de17 June 2014 Annals of Internal Medicine Volume 160 • Number 12 823
Original Research
Internists’ Attitudes Toward Prevention of Firearm Injury
Table 2. Importance of a U.S. Plan to Prevent Firearm Violence, by Demographic Characteristics* Importance of a Plan to Prevent Firearm Violence, %
Characteristic Extremely Important (n ⴝ 291)
Very Important (n ⴝ 156)
Moderately Important (n ⴝ 82)
Not Too Important (n ⴝ 24)
Not at All Important (n ⴝ 15)
Not Sure (n ⴝ 5)
Total respondents
51
27
14
4
3
1
Age group ⱕ39 y 40–55 y ⬎55 y
49 50 55
31 28 23
16 13 14
3 5 6
1 5 2
1 1 1
Sex Male Female
49 56
27 26
15 14
4 3
3 1
1 0
Race White Nonwhite Not specified
48 59 42
25 27 39
17 10 12
6 2 5
3 2 2
1 1 0
Region of country Midwest Northeast South West
50 60 43 51
30 26 26 27
11 9 18 18
4 3 7 3
3 1 5 1
2 1 1 0
Physician status In training Practicing
45 52
34 26
15 14
4 4
2 3
1 1
Specialty General internal medicine Internal medicine subspecialty
49 55
30 22
13 17
4 4
3 2
1 0
Practice setting Office-based practice Academic medical center/medical school Hospital Government facility Community health center/clinic Retired Other
51 51 52 50 39 47 63
21 30 26 36 45 35 17
19 13 12 11 6 12 13
3 5 7 0 6 6 4
5 1 3 2 0 0 0
1 0 0 2 3 0 4
Gun owner in home Yes No
33 56
23 28
26 11
7 3
8 1
3 1
Time spent in direct patient care Yes No
50 61
27 26
15 7
4 0
3 3
1 3
* Percentages may not sum to 100 due to rounding.
signed to increase the knowledge and skills of physicians in how to counsel patients in the prevention of firearm injury, 74% of respondents replied “somewhat/to a great extent” (Appendix Table 3, available at www.annals.org). In addition, 66% of respondents would be very or somewhat interested in participating in an educational program to help them counsel their patients on the prevention of firearm injury. Non– gun owners more often reported interest in such a program than did those from a home with gun owners (69% vs. 58%). Twelve percent of respondents believed that ACP should make reducing gun violence in this country its 824 17 June 2014 Annals of Internal Medicine Volume 160 • Number 12
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highest priority, and an additional 51% believed that it should be a high priority but not its highest. This compares with one third of all respondents who believed that ACP should give reducing gun violence a lower priority (25%) or no priority (8%).
DISCUSSION Most internists who responded to our survey believed that firearm-related violence is a public health issue. In addition, most respondents favored policy initiatives aimed at reducing the problem. Most responding internists bewww.annals.org
Internists’ Attitudes Toward Prevention of Firearm Injury
Original Research
ive of certain policies than the general public. More than 80% of the internists included in the current survey supported banning the possession of assault weapons except by military and other authorized persons and banning highcapacity magazines, whereas only slightly more than one half of the general public reported supporting such measures in the Pew Research Center study (13). Although it is not possible to draw confident conclusions comparing the populations surveyed, it does seem, on the basis of these findings, that support for changes in policy aimed at gun violence is greater among physicians than the U.S. population in general. Although most respondents in our study believed that it is appropriate for physicians to counsel patients on gun safety, most reported not asking their patients about gun ownership or gun safety. Respondents with a gun owner in the home more often reported asking their patients about gun use than did those without a gun owner in the home.
lieved that physicians should have the right to counsel their patients about firearm-related violence. Despite that, few internists reported currently engaging in such patient counseling. These data may be useful in the development of policy initiatives and educational resources. These data are consistent with results from the 1996 study of internists, as well as a recent survey of the U.S. general population. Our survey in 1996 found that 94% of internists viewed firearm violence as a public health issue and 84% believed that stricter gun regulation would help to reduce gun injury or death. A national public survey conducted in January 2013 by the Pew Research Center found strong support (95% of respondents) for mandatory background checks on all gun purchases and preventing persons with mental illness from purchasing guns (80%). Although each of these surveys found that most respondents supported policies to regulate firearms, the physicians who responded to our survey seemed to be more support-
Figure 1. Attitudes of respondents toward firearm injury and prevention. 80% 60%
Firearm injury is a public health issue
40% 20%
61
49
26
28
8
10
4
2
1
10
1
1
37
27
21
27
15
7
6
16
2
3
27
27
30
12
11
7
17
1
12
5
3
31
32
26
17
15
8
12
6
15
1
1
26
24
23
6
6
6
14
4
27
1
3
29
39
39
37
11
8
4
3
2
5
7
18
18
34
25
28
13
13
14
3
2
0% 80%
Physicians should be involved in prevention 60% 40% of firearm injury 20%
19
0%
Gun violence is a bigger problem than it was a decade ago
It is appropriate for physicians to counsel patients about gun control
80% 60% 40% 20% 0%
48
80% 60% 40% 20% 0%
Stricter gun control legislation will help to reduce risks for gun-related injury or death
80% 60% 40% 20% 0%
Increased government spending on mental health screening and treatment would help to reduce the risks for gunrelated injury or death
80% 60% 40% 20% 0%
36
58
20
16
80% 60%
No Gun Owner in Home (n = 452)
ot S
St
ro n
gl y
N
D
isa
isa
gr ee
gr ee
8
tD ha
24
ew
ha t ew m So
St
ro n
gl y
Ag r
Ag re e
ee
0%
So m
20%
ur e
40%
N ei no the rD rA isa gre gr e ee
Physicians should obtain training on prevention of firearm injury
Gun Owner in Home (n = 121)
The y-axis shows the percentage of respondents with opinions about each category. www.annals.org
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17 June 2014 Annals of Internal Medicine Volume 160 • Number 12 825
Original Research
Internists’ Attitudes Toward Prevention of Firearm Injury
Figure 2. Percentage favoring various firearm-related initiatives. Mandatory background check on all gun purchases regardless of whether through an authorized dealer, gun show, or other private sale Mandatory registration of all guns, including handguns, rifles, shotguns, and semiautomatic weapons Mandatory safety training before buying a gun
Banning the possession of assault weapons except by the military and other authorized persons Banning the possession of high-capacity magazines except by the military and other authorized persons Banning armor-piercing bullets
Preventing persons with mental illness from purchasing guns Preserving the rights of physicians to counsel their patients on preventing deaths and injuries from firearms Improving access to mental health services
Requiring safety features to make guns more child-proof
Banning sale of firearms to persons younger than 21 y
Creating a federal database to track gun sales 0
20
40
60
80
100
Favoring Measure, % No Gun Owner in Home (n = 452)
This may be due to greater familiarity with guns and appropriate safety measures. The lack of training on the issue could be a barrier for non– gun owners. Most responding internists believed that there is a need for an educational program to increase the knowledge and skills of physicians in how to counsel their patients. This is an important message for medical schools, residency programs, and organizations that provide continuing medical education. It is also promising because the evidence already supports the important role that physicians can play in the prevention of firearm injury. Patients and families of those who risk firearm injury have indicated a willingness to discuss concerns and safety options with their physicians (11). Counseling efforts by physicians have been shown to make a positive effect in the firearm storage habits of their patients (12, 14). Not only is it important for physicians to become properly educated about the risks 826 17 June 2014 Annals of Internal Medicine Volume 160 • Number 12
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Gun Owner in Home (n = 121)
of firearm ownership and the need for safety measures, but it is also essential that they be taught how to communicate this to their patients through proper screening, counseling, and education. A greater understanding of risk factors for suicide and identification of persons who are at risk for harming themselves or others is also important. Our study had several notable strengths and limitations. We surveyed a well-characterized, nationally representative cohort of internists. Despite a 56.5% response rate, there were no obvious differences between persons who did or did not respond (differences would suggest the risk of participation bias), although we cannot definitively exclude the possibility of bias. Our data reflect physicians’ reported attitudes but cannot assess their actual behavior in practice. Because the survey was conducted soon after a mass shooting in Newtown, Connecticut, which involved the murder of school children, the lingering emotional www.annals.org
Internists’ Attitudes Toward Prevention of Firearm Injury
effect of this event may have influenced respondents’ attitudes about preventing firearm injury. In addition, we surveyed only physicians trained in internal medicine, although our respondents reflect a wide array of generalists and subspecialists. Future research should evaluate the reasons why physicians do not currently ask patients about the presence of guns in their environment or measures to promote firearm safety. Although we found that 80% of physicians did not ask such questions, we did not ask why. Data on the types of educational programs or materials related to firearm safety that physicians believe would be beneficial and in which they would participate may also be useful as medical schools and professional organizations aim to enhance educational efforts at reducing the public health threats of firearm violence. Patients have long trusted their physicians to advise them on issues affecting their health. Firearm violence is a public health problem in which physicians may play a critical role. Our survey suggests that most internists would support initiatives that would engage physicians in efforts to prevent gun-related violence from harming their patients and communities. Greater emphasis on understanding the types of programs that would provide the greatest benefit and how to implement them is warranted. From the American College of Physicians, Washington, DC, and Philadelphia, Pennsylvania. Disclosures: Authors have disclosed no conflicts of interest. Forms can
be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms .do?msNum⫽M13-1960. Reproducible Research Statement: Study protocol, statistical code, and
data set: Available from Dr. Weissman (e-mail, aweissman@acponline .org). Requests for Single Reprints: Renee Butkus, BA, American College of Physicians, 25 Massachusetts Avenue NW, Washington, DC 20001; e-mail, [email protected].
Current author addresses and author contributions are available at www.annals.org.
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Original Research
References 1. Richardson EG, Hemenway D. Homicide, suicide, and unintentional firearm fatality: comparing the United States with other high-income countries, 2003. J Trauma. 2011;70:238-43. [PMID: 20571454] 2. Centers for Disease Control and Prevention. Injury Prevention & Control: Data & Statistics (WISQARS). Atlanta, GA: Centers for Disease Control and Prevention; 2014. Accessed at www.cdc.gov/ncipc/wisqars on 12 May 2013. 3. Hoyert DL, Xu J. Deaths: Preliminary Data for 2011. National Vital Statistics Reports. Hyattsville, MD: U.S. Department of Health and Human Services; 2012;61:1-65. 4. Centers for Disease Control and Prevention. FastStats. Suicide and SelfInflicted Injury. Atlanta, GA: Centers for Disease Control and Prevention; 2013. Accessed at www.cdc.gov/nchs/fastats/suicide.htm on 12 May 2013. 5. Cassel CK, Nelson EA, Smith TW, Schwab CW, Barlow B, Gary NE. Internists’ and surgeons’ attitudes toward guns and firearm injury prevention. Ann Intern Med. 1998;128:224-30. [PMID: 9454531] 6. American Academy of Orthopaedic Surgeons. July 1996 Bulletin. Position Statement: Firearms Violence. Rosemont, IL: American Acad of Orthopaedic Surgeons; 1996. Accessed at www2.aaos.org/bulletin/jul96/position.htm on 29 January 2014. 7. American Public Health Association. Policy Statement: Handgun Injury Reduction. Washington, DC: American Public Health Assoc; 1 January 1998. Accessed at www.apha.org/advocacy/policy/policysearch/default.htm?id⫽170 on 29 January 2014. 8. Bronson DL. Statement of the ACP: Reducing Firearms-Related Deaths and Injuries. Philadelphia: American Coll of Physicians. 20 December 2012. Accessed at www.acponline.org/acp_policy/policies/reducing_firearms-related_deaths_and _injuries_2012.pdf on 19 June 2013. 9. Bronson DL. Letter to Sen. Harry Reid supporting legislation to reduce firearms-related deaths and injuries. Philadelphia: American Coll of Physicians; 5 April 2013. Accessed at www.acponline.org/acp_policy/letters/reid_legislation _to_reduce_firearms_injuries_2013.pdf on 19 June 2013. 10. Laine C, Taichman DB, Mulrow C, Berkwits M, Cotton D, Williams SV. A resolution for physicians: time to focus on the public health threat of gun violence [Editorial]. Ann Intern Med. 2013;158:493-4. [PMID: 23277894] 11. Gardner W, Klima J, Chisolm D, Feehan H, Bridge J, Campo J, et al. Screening, triage, and referral of patients who report suicidal thought during a primary care visit. Pediatrics. 2010;125:945-52. [PMID: 20385642] 12. Albright TL, Burge SK. Improving firearm storage habits: impact of brief office counseling by family physicians. J Am Board Fam Pract. 2003;16:40-6. [PMID: 12583649] 13. Pew Research Center for the People and the Press. In Gun Control Debate, Several Options Draw Majority Support. Washington, DC: Pew Research Center for the People and the Press; 2013. Accessed at www.people-press.org/2013/01/ 14/in-gun-control-debate-several-options-draw-majority-support on 19 June 2013. 14. Carbone PS, Clemens CJ, Ball TM. Effectiveness of gun-safety counseling and a gun lock giveaway in a Hispanic community. Arch Pediatr Adolesc Med. 2005;159:1049-54. [PMID: 16275796]
17 June 2014 Annals of Internal Medicine Volume 160 • Number 12 827
Annals of Internal Medicine Current Author Addresses: Ms. Butkus: American College of Physicians, 25 Massachusetts Avenue NW, Washington, DC 20001. Dr. Weissman: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
Author Contributions: Conception and design: R. Butkus, A.
Weissman. Analysis and interpretation of the data: R. Butkus, A. Weissman. Drafting of the article: R. Butkus, A. Weissman. Critical revision of the article for important intellectual content: R. Butkus. Final approval of the article: R. Butkus, A. Weissman. Administrative, technical, or logistic support: R. Butkus. Collection and assembly of data: A. Weissman.
Appendix Table 1. Support by Internists for Specific Measures to Deal With Firearm Violence Respondents Who Favor Measure, %
Measure
Mandatory background check on all gun purchases regardless of whether through an authorized dealer, gun show, or other private sale Mandatory registration of all guns, including handguns, rifles, shotguns, and semiautomatic weapons Mandatory safety training before buying a gun Banning the possession of assault weapons except by the military and other authorized persons Banning the possession of high-capacity magazines except by the military and other authorized persons Banning armor-piercing bullets Preventing persons with mental illness from purchasing guns Preserving the rights of physicians to counsel their patients on preventing deaths and injuries from firearms Improving access to mental health services Requiring safety features to make guns more child-proof Banning sale of firearms to persons younger than 21 y Creating a federal database to track gun sales
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Total (n ⴝ 573)
Gun Owner in Home (n ⴝ 121)
No Gun Owner in Home (n ⴝ 452)
95
88
97
81
50
89
88 86
74 63
91 92
85
68
89
87 85 86
79 85 84
89 85 86
97 86 83 79
98 67 63 60
96 91 88 84
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Appendix Table 2. Frequency of Discussions About Gun-Related Issues Frequency of Discussion, %*
Issue Total Respondents (n ⴝ 542)†
Respondents With Gun Owner in Home (n ⴝ 112)
Respondents Without Gun Owner in Home (n ⴝ 430)
Whether the patient has guns in his/her home Always Sometimes Never
3 39 58
5 48 46
3 37 60
Whether the patient uses guns even if a gun is not present in the home Always Sometimes Never
1 19 80
1 23 76
1 18 81
Ways to reduce the risk for gun-related injury or death Always Sometimes Never
2 21 77
2 28 71
2 19 79
Importance of keeping guns in the home away from children Always Sometimes Never
6 32 62
12 39 49
5 30 65
Voluntarily removing the gun from the home Always Sometimes Never
1 22 77
1 31 68
1 20 79
* Percentages may not sum to 100 due to rounding. † Respondents who reported time spent in direct patient care.
Appendix Table 3. Interest in Education Interest in Education, %
Issue Total Respondents (n ⴝ 542)*
Respondents With Gun Owner in Home (n ⴝ 112)
Respondents Without Gun Owner in Home (n ⴝ 430)
Comfort in reporting a patient who threatens to harm himself/herself or others to the background-check system Very comfortable Somewhat comfortable Not comfortable Not sure
40 37 13 10
52 26 14 8
36 40 13 11
Agree with the need for an educational program designed to increase the knowledge and skills of physicians in how to counsel patients in the prevention of firearm injury To a great extent Somewhat Not too much Not at all Not sure
30 44 14 8 4
24 38 20 15 3
32 45 13 6 4
Interest in participating in an educational program on how to counsel patients in the prevention of firearm injury Very interested Somewhat interested Not too interested Not at all interested Not sure
23 43 20 11 3
22 36 22 20 0
24 45 19 9 3
* Respondents who reported time spent in direct patient care. 17 June 2014 Annals of Internal Medicine Volume 160 • Number 12
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