Renee Butkus, BA; Arlene Weissman, PhD
This article was published online first at www.annals.org on 10 April 2014.
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, email@example.com).
Requests for Single Reprints: Renee Butkus, BA, American College of Physicians, 25 Massachusetts Avenue NW, Washington, DC 20001; e-mail, firstname.lastname@example.org.
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.
Butkus R., Weissman A.; Internists’ Attitudes Toward Prevention of Firearm Injury. Ann Intern Med. 2014;160:821-827. doi: 10.7326/M13-1960
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Published: Ann Intern Med. 2014;160(12):821-827.
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.
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.
Internal medicine practices.
573 internists representative of American College of Physicians’ members.
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.
The survey response rate was 56.5%. Eighty-five percent of respondents believed that firearm injury is a public health issue, 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.
The generalizability of these findings to non–American College of Physicians’ member internists and other physicians is unknown. Responses may not reflect actual behavior.
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.
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.
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.
The study included only internists, and it could not evaluate actual practice.
Physician support may be useful in efforts to reduce firearm-related violence.
The 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 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 first-hand 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.
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.
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.
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 firearms, 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).
No external funding was obtained for this survey.
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).
Table 1. Characteristics of Survey Respondents
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%). Sixty-four 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%). Forty-four percent reported keeping a gun for protection.
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%).
Table 2. Importance of a U.S. Plan to Prevent Firearm Violence, by Demographic Characteristics
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 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.
Attitudes of respondents toward firearm injury and prevention.
The y-axis shows the percentage of respondents with opinions about each category.
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.
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). Ninety-seven percent of respondents favored improving access to mental health services, and 85% favored preventing persons with mental illness from purchasing guns.
Appendix Table 1. Support by Internists for Specific Measures to Deal With Firearm Violence
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%).
Percentage favoring various firearm-related initiatives.
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 risk for gun-related injury or death, and 62% reported never discussing the importance of keeping guns away from children (Appendix Table 2). 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 designed 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). 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%).
Appendix Table 2. Frequency of Discussions About Gun-Related Issues
Appendix Table 3. Interest in Education
Twelve percent of respondents believed that ACP should make reducing gun violence in this country its 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%).
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 believed 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 supportive 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 high-capacity 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. 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 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 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.
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Thomas F Heston MD
Assistant Professor (Adjunct), Johns Hopkins University
April 13, 2014
A Statistical Solution to Low Response Rates
This study had a low response rate that potentially resulted in a self-selection sampling bias. Although the authors suggested that the non-response bias was overcome by showing demographic data that respondents were similar to the non-respondents, we currently have no consistent way to deal with non-random missing data (1). I believe that the method I propose here is a valid, conservative, and new solution that can be utilized to overcome non-response bias.In this study, 324 out of 573 internists surveyed responded. Out of these, 85% (275) believed that gun violence was a pubic health issue. A conservative way to handle non-random missing data in such surveys is to assume that the bias in non-respondents is equally strong, but in the opposite direction. Using this method, we apply the positive response rate in the respondents to the non-respondents, but in the opposite direction. In this study there were 249 non-respondents. Assume that 85% of non-respondents believe that gun violence is NOT a public health issue and that 15% (37/249) believe the opposite. Combining the results of the respondents with the non-respondents, we estimate that 312 out of 573 (55%) believe gun violence is a public health issue. The 95% confidence interval for this proportion is 44% to 65%, and the alternative hypothesis (that most internists believe gun violence is a public health issue) can be rejected.By extension, this method also provides a way to determine an adequate response rate. In this case, a response rate of at least 66% is necessary as demonstrated below.A 66% response rate would mean that 378 out of 573 surveyed responded. Of the respondents, if the 85% rate held true, 321 would state gun violence is a public health issue. Of the 195 non-respondents, we estimate that 29 (15%) agree. Combining the results, we estimate that 350 out of 573 (61%) believe gun violence is a public health issue. The 95% confidence interval for 350/573 is 51% to 72%, and the alternative hypothesis is confirmed.Since the response rate from this survey was only 56.5%, it does not meet the required threshold of 66% demonstrated above. Therefore, the conclusion that internists as a group believe that gun violence is a public health issue can be hypothesized, but not confirmed.REFERENCES1. Altman DG, Bland JM. Missing Data. BMJ. 2007 Feb 24;334(7590):424.
James Webster, MD, MS, MACP
June 30, 2014
This ACP policy paper (1) is a comprehensive, authoritative, compendium of facts and
recommendations which describe why and how the U. S. can achieve significant reductions in firearm
related injuries and deaths. It correctly identifies gun violence (GV) as a major public health issue. With
more than 30,000 deaths and over 70,000 injuries each year GV most certainly qualifies as a major
epidemic. It is crucial that the recommendations of the paper now be prioritized into action initiatives.
Specifics could include:
• Convening a permanent ACP sponsored task force on the topic. This multidisciplinary coalition[recommendation 1.a (1)] could provide leadership for the entire profession as it generates
Specific goals, objectives and tactics on a continuing basis.
• Mobilizing the considerable resources and prestige of the ACP to craft and present draft
legislation to Federal lawmakers to reduce GV. Such templates could also be used by
Chapters on a local State basis. These bills could address the regulation of gun sales [recommendations 3, a,b,c,d,e, (1)] and improving the safety of weapons for owners [recommendations 7.8 (1)].
• Developing educational materials for physicians to distribute and discuss with patients and
families on the risks, responsibilities and safety measures for gun owners [recommendations 2 b and 5 (1)].
• Producing and disseminating curricular materials for physician education on various aspects of
GV. This would empower internists to better be able to educate, advise, and counsel patients
(2) about issues of prevention surrounding GV. This could be used at Chapter and
National meetings, in CME venues and by training programs [reco0mendation 2, b,c (1)].
• Supporting broad research on the topic of GV, even perhaps using seed money grants.
[recommendation 9 (1)].
There are clearly other projects that ACP could consider regarding GV, an area that is calling out
for leadership and collective action. These activities are totally consistent with the ACP’s
mission and how the ACP has responded to other epidemics and medical crises such as obesity,
Diabetes and the public health disaster in Haiti. This initiative would be a very cost efficient use
of ACP resources. Unless the position paper is followed up with action steps it may only gather
dust and tragically could all too soon be forgotten.
1. Butkus R. Doherty R, Daniel H. Reducing firearm-related injuries and deaths in the United States:
Executive summary of a policy position paper from the American College of Physicians. Ann Intern Med.
2.Butkus R, Weissman A. Internists’ attitudes toward prevention of firearm injury. Ann Intern Med.
Healthcare Delivery and Policy.
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