Internists' and Surgeons' Attitudes toward Guns and Firearm Injury Prevention

The high rates of death, injury, and long-term disability related to firearms in the United States have led to growing concern in the health care community. Many existing legislative and regulatory measures focus on reducing injury and death from firearms. Debates about these often controversial gun control proposals usually revolve around disagreements about their potential impact on crime and strategies for crime reduction. However, because most deaths from firearms are the result of domestic disputes, unintentional injury, or suicide, the paradigm of firearm violence as a problem of criminal justice is increasingly complemented by the view of firearm injury as a public health problem [1-3]. Several medical organizations, including the American Medical Association, the American Public Health Association, and the National Medical Association, have called for increased attention from the medical community to this issue. Moreover, the American Academy of Pediatrics, the American Pediatric Surgical Association, the American Trauma Society, and the Eastern Association for the Surgery of Trauma have adopted or proposed policies on control of firearm violence [4-9]. Medical journals have published editorials [10-18], hosted formal debates [19], issued calls for papers, organized special theme issues [10, 12, 20, 21], and published policy-oriented papers [22-29] on gun violence, all of which prompted brisk responses in letters to the editor [30-44]. The literature on gun violence has been growing with several notable studies done on the relation between gun violence and death [21, 45-58]. Despite the increased reframing of the issue, few studies have examined the attitudes and practices of physicians in relation to firearms. These include studies of pediatricians [59-61], subscribers to Physician's Management [62], physicians in Portland, Oregon [63], and directors of the nation's trauma centers [64]. Firearm injury appears in the clinical prevention literature. Physicians are urged to inquire about guns in the house and counsel patients about firearm safety measures [65, 66]. To describe and define more clearly the attitudes of physicians toward guns and prevention of firearm-related injury, we designed a survey and administered it to the membership of the American College of Physicians (ACP) and the American College of Surgeons [ACS]. These organizations are the two largest medical specialty societies in the United States, representing approximately 100 000 internists and 68 000 surgeons, respectively. We report descriptive results and add to the literature on physician attitudes by answering the following questions: 1) To what extent do internists and surgeons view firearm violence, injury, and deaths from a public health perspective? 2) What roles, if any, do internists and surgeons see for physicians with regard to firearm violence? 3) What public policies do internists and surgeons support for the regulation of firearms? Methods Study Sample We drew a random sample of ACP and ACS members. Each association maintains its members in a random listing. In preparation for sampling, ACP and ACS removed ineligible members from the total list of members. Selected segments of the memberships were then excluded to yield a sample of actively employed, nonmilitary physicians living in the United States. The remaining members were sorted according to the four regions of the United States (northeast, south, midwest, and west) to assure regional representation. A two-stage sampling technique was used. In the first stage, a random start was chosen and every nth member was selected (n was determined by dividing the number of members in each region by 300). The total number of physicians eligible for inclusion in the sample across both associations was 94 271. To achieve estimates with 95% probability of accuracy with an error rate of 5%, a total of 800 completed interviews (400 from each association) was required. On the basis of an anticipated 40% response rate, we drew a sample of 2409 physicians (1209 from ACP and 1200 from ACS) from all four regions. In the second stage, 2019 physician names were released to the interviewers; the remainder were held in reserve in case the requisite number of interviews could not be completed with the initial larger set. From this set, appointments were then made for interviewing. We used a practice common in telephone interviewing: Once the sample was selected, we began interviewing a subset of participants randomly selected from the whole sample until the number of required interviews was reached. The total number of participants released to the interviewers from the whole sample then became the denominator in determining response rate; this denominator was less than the number of participants in the whole sample. A total of 1108 of the 2019 internists and surgeons were contacted and asked to participate before the target number of completed interviews was reached. Of the physicians contacted, 915 completed interviews (457 from ACP and 458 from ACS). The 115 interviews beyond the target of 800 resulted from interview appointments that had been made before the required number of completed interviews had been reached. The compliance rate was 82.5% (915 completed interviews 1108 physicians who were contacted [that is, 193 refusals + 915 interviews]) and the overall response rate was 45.3% (915 completed interviews 2019 physicians in the sample released to the interviewers). Questionnaire and Data Collection By using the literature on firearm violence and guidance from recognized experts in the field, we identified six domains of importance: physician-clinician experience with firearms, knowledge about clinical sequelae of firearm injury, knowledge about public policies on firearm violence, attitudes toward public policies on firearm violence, clinical practice behavior, and education and training. The questionnaire was revised after being pretested by telephone interviews with 31 ACP members and 20 ACS members. The final version was a 55-item instrument that took an average of 14 minutes to complete. Response categories included yes/no, favor/oppose, 3- and 5-point Likert scales, and categorical selections. Data Analysis The National Opinion Research Center, an independent research firm, converted the questionnaire into a computer-assisted telephone interview format and conducted the interviews. Data were collected between 19 January 1996 and 12 February 1996. Statistical Analysis We used descriptive and bivariate statistical techniques. Unstandardized and standardized weights were produced. The unstandardized weight represented the number of internists and surgeons in the target population who were represented by each participant in that stratum. Because the weights varied greatly, we used weighted values in the analysis. The average unstandardized weight across the strata was 103; this meant that on average, each study participant represented about 103 internists or surgeons in the U.S. target population. The standardized weights were used to estimate the SEs of the means and proportions and to perform Pearson chi-square testing for significance. Because our report involves comparisons of multiple responses from the same physicians, we used adjusted critical P values of 0.001, 0.002, and 0.003 to judge the statistical significance of individual comparisons within a table (Bonferroni correction) so that the family-wise type I error rate was limited to 0.05 for each set of comparisons. Results Demographic Characteristics As a group, the respondents were representative of the ACP and ACS memberships, adjusted for age, sex, ethnicity, and regional distribution (Table 1). Table 1. Characteristics of Survey Respondents (n = 915) Firearm Violence as a Public Health Issue Most respondents (94% of internists and 87% of surgeons) agreed that firearm violence has become a major public health issue. Support for a public health perspective was greatest among physicians who were not raised in households that had guns, did not currently own guns, belonged to gun control organizations, and were not members of gun clubs. Physicians who endorsed the public health position tended to be female, younger, and currently practicing in large cities (Table 2). Although support for the public health perspective was not related to negative experiences with guns, attitudes toward some medical practice variables were (Table 3). Physicians who took a public health perspective on guns tended to think that it is appropriate for physicians to offer counseling on firearm safety, to believe the medical literature on guns, to think that physicians should be involved in firearm injury prevention, and to think that violence prevention should be a priority for physicians. Table 2. Relation between Demographic Variables and the Belief That Firearm Violence Is a Public Health Issue Table 3. Relation of Attitudes of Internists and Surgeons toward Guns and Firearm Injury to the Belief That Gun Violence Is a Public Health Issue Firearm Violence and the Role of Internists and Surgeons Respondents supported two roles for physicians. One concerned the involvement of internists and surgeons in community efforts that address firearm violence. Fewer surgeons than internists (64% and 84%) thought that physicians should support community efforts to enact legislation restricting the possession or sale of handguns. The other role concerned the clinical implications of firearm violence and their bearing on individual physician practices. Most internists and surgeons (84% and 72%) thought that physicians should be involved in firearm injury prevention. Furthermore, 88% of internists and 78% of surgeons believed the medical literature that describes the increased risk for gun injury associated with having guns in the home (Table 3). Among respondents who provided direct patient care, few currently include firearm safety counseling in their clinic