This Is Our Lane: Bringing Gun Violence Prevention to Medical Education and Clinical Care

Peter T. Masiakos, MD, MS, FACS, FAAP

While many national health professional organizations have stated it is the responsibility of physicians to discuss firearm safety with their patients, few clinicians do – even among high-risk patients (for example, among those who have expressed suicidal or homicidal ideation). In June 2019, Massachusetts General Hospital launched the MGH Center for Gun Violence Prevention with a mission focused on clinical care and education, research, and community engagement with the goal of reducing morbidity and mortality from firearm-related violence. Our Center’s early quality improvement work determined that many of the reasons underlying this lack of directed counseling among clinicians were straightforward: few clinicians had received training in how to have these conversations or knew what to do next if a patient or family member did report having firearms at home.

To begin to fill these knowledge and practice gaps, we developed an innovative training program to empower healthcare providers with tools to discuss this issue with patients in a culturally competent way. We assembled a team of resident and attending physicians— gun owners and non-gun owners--from across disciplines (including internal medicine, surgery, pediatrics, psychiatry, obstetrics/gynecology, and emergency medicine) to develop a didactic introduction and provide authentic and relevant clinical cases unique to each discipline. We then hired and trained a team of standardized patients. With buy-in from the residency program leadership in each department, every incoming intern in these departments at MGH in the summer of 2019-2021 went through a mandatory training. This didactic session teaches an evidence-based framework for incorporating violence prevention and firearm safety screening into clinical care, followed by a case-based simulation session to practice these skills. Since 2019, nearly 600 residents, medical students, and nurses have been trained in at least four other medical institutions: Harvard Medical School; Tufts School of Medicine; Dell Children’s Hospital’s emergency medicine residency program; Boston University’s Physician Assistant program; and Rutgers School of Nursing.

In our analysis of the first year of this work, we determined that 70% of participants reported having had no prior training related to gun violence prevention and only 3% of participants reported knowledge of resources available at our institution and in Massachusetts to help facilitate conversations with patients. For example, prior to the training, 3% of participants were aware of Extreme Risk Protection Orders, a law passed in 19 states including Massachusetts to facilitate removal of firearms from persons who may be an imminent risk to themselves or others, and of how to appropriately use this law. After the training, 98% reported awareness. In addition to review of these data, we conducted qualitative feedback sessions with the participating standardized patients to elicit feedback and improve the clinical cases. Overall, we concluded that this case-based gun violence prevention training program was feasible with good uptake in a single institution. We also sought to formalize this training as a part of residency curricula to ensure its continuation year-to-year as well as to explore partnerships to 1) improve this training and 2) expand its reach beyond MGH.

During the 2020-2021 academic year, the emergence of the COVID-19 pandemic presented challenges to our training program, which had been characterized by close in-person standardized patient-learner interactions. We adapted and redesigned the sessions to be able to implement them by remote (Zoom-based) simulations. With shortened, remote orientations for incoming interns, making this part of every orientation was not possible, therefore we have sought to embed this training in other parts of the curriculum. We successfully completed the Zoom-based curriculum in several departments, and this has been integrated in our standard approach to expand opportunities for remote learning throughout the academic year.

Along the lines of expansion, we have developed a virtual reality (VR) curriculum based on an existing standardized patient curriculum created by the MGH Center for Gun Violence Prevention. Curricular objectives have been established and simulation flowsheets have been developed by experts in medical education at Cincinnati Children’s Hospital Medical Center (CCHMC). This novel platform allows clinicians to deliberately practice screening and counseling on gun injury and is currently undergoing formal usability testing. The next phase of our work will be a randomized controlled pilot study assessing the comparative efficacy of Resident Education and Counseling on Household REACH Firearm Safety versus standard training at CCHMC and MGH as measured by documented discussion of gun violence prevention topics during pediatric outpatient clinic visits. This will support broader assessment of implementation metrics of VR-based training to inform future scale and spread. Additionally, in alignment with our confidence in this approach, we aim to begin foundational work to inform expansion of the VR platform for training school-based nurses and counselors in gun violence prevention strategies.

Our society often addresses healthcare problems only after they occur. It is clearly preferable to prevent deaths and injuries rather than to treat them. As health care clinicians and educators, we must stand front and center to address the gun violence epidemic. We are hopeful that the foundation of the novel work described here will elevate the voices of our diverse community of key stakeholders, centering their perspectives in decision-making, and identifying upstream opportunities where we could interrupt the cycle of preventable gun violence.

Peter T. Masiakos, MD, MS, FACS, FAAP is an Associate Professor of Surgery at Harvard Medical School, Director Pediatric Trauma Services at the Massachusetts General Hospital, and Co-Director of the MGH Center for Gun Violence Prevention.

Recent Scholarly Publications from the MGH Center for Gun Violence Prevention:

• Naureckas Li C, Sacks CA, Cummings BM, Samuels-Kalow M, Masiakos PT, Flaherty MR. Improving Pediatric Residents’ Screening for Access to Firearms in High-Risk Patients Presenting to the Emergency Department. Acad Pediatr. 2021 Jan 09. PMID: 33429102.

• Masiakos PT, Sacks CA. Moving beyond descriptions-developing a strategy to prevent gun violence. Surgery. 2020 Sep; 168(3):385-386. PMID: 32654860

• Sacks CA, Bartels SJ. Reconsidering Risks of Gun Ownership and Suicide in Unprecedented Times. N Engl J Med. 2020 06 04; 382(23):2259-2260. PMID: 32492309.

• Gondi S, Pomerantz AG, Sacks CA. Extreme Risk Protection Orders: An Opportunity to Improve Gun Violence Prevention Training. Acad Med. 2019 11; 94(11):16491653. PMID: 31397705.

• Naureckas Li C, Sacks CA, McGregor KA, Masiakos PT, Flaherty MR. Screening for Access to Firearms by Pediatric Trainees in High-Risk Patients. Acad Pediatr. 2019 08; 19(6):659664. PMID: 30853577.