At 6 p.m. on a chilly December day, Chana Sacks, MD, got the call: Her cousin’s son Daniel, 7, was dead.
The boy, a first-grader, was one of 20 children killed by a shooter at Sandy Hook Elementary School in Newtown, Connecticut, in 2012. Sacks still remembers the funeral with its tiny white casket and the firefighters who came to honor Daniel because they’d heard he hoped to become one.
After the shooting, Sacks immersed herself in studying the existing research on preventing firearm-related violence. And together with several colleagues, she used that research to create a gun violence prevention curriculum for hundreds of residents at Massachusetts General Hospital (MGH), where she is an internist and health policy researcher.
“This work certainly has its many challenges, but I feel I have no choice but to do it,” she says.
Other educators involved in the movement to teach medical students and residents to better understand and prevent firearm-related harms may not be driven by such a personal loss. For them, the data are motivation enough.
In the United States, firearm fatalities rose to a 28-year high in 2021, and the firearm homicide rate leapt 45% between 2019 and 2021. Forty percent of U.S. adults own a firearm, and an estimated 4.6 million children live in homes with a loaded and unlocked gun.
“More and more, physicians see our role as not just treating a wounded patient in the trauma bay … but also addressing prevention and the effects that reverberate into families and communities.”
Chana Sacks, MD
Massachusetts General Hospital
Meanwhile, medical education related to firearms has been thin. In a 2018 survey, for example, only 22% of pediatric residents reported learning about the topic.
“I recognize that there’s a lot to learn in medical school, but when you consider how many people are dying from firearms and how many will live with lifelong injuries, there isn’t nearly enough of a focus on this,” says Anita Knopov, MD, an emergency medicine resident who helps lead firearm-related education at the Warren Alpert Medical School of Brown University in Providence, Rhode Island.
Although such a focus is still not widespread, it is growing significantly, experts say.
“Around a decade ago, many of the conversations were about trying to convince people that gun violence prevention education is important. Over the last three or four years, the conversation has shifted to, ‘What should we do?’” says Sacks.
Some numbers support that shift. During the 2018-19 school year, 16% of reporting medical schools offered firearm-related content compared with 25% two years later, AAMC data show.
Often, curricula focus on helping trainees learn how to talk to patients about safety. Students need to learn to handle potentially tough conversations, educators say, especially since many patients may not be receptive. Roughly a third of Americans believe firearms should not be the purview of patient encounters, according to one national survey.
But given that physicians must treat firearm injuries when they happen, they increasingly feel a duty to help prevent them.
“More and more, physicians see our role as not just treating a wounded patient in the trauma bay … but also addressing prevention and the effects that reverberate into families and communities,” says Sacks.
What do students need to know?
Determining what to include in firearm-related education is no simple matter. One place educators can turn is the first national consensus guidelines covering what all physicians — whatever their medical specialty — should know about firearms.
The document, released in January by an advisory group that included the AAMC, lists several crucial skills. Those range from understanding factors that can fuel gun violence to referring survivors to supportive services.
“The more we take a broad, bio-psycho-social approach, the more learners will understand the scope of firearm injury and the effects it can have on all aspects of a person's life,” says Stephen Hargarten, MD, MPH, an emergency medicine professor at the Medical College of Wisconsin who has taught about firearm injuries for decades.
Of course, what trainees learn and how varies by institution. At Brown, for example, educators are weaving content into relevant curricula throughout all four years of medical school. At the McGovern Medical School at UTHealth Houston, meanwhile, educators provide a required one-hour training for first-year students as well as six hour-long electives on topics such as the psychology of mass shooters.
Despite the different approaches, certain themes recur. For one, many trainees learn the basics of safe firearm storage.
At UTHealth Houston, students and residents view an instructional video on safety devices for handguns, shotguns, and rifles.
“I show me using my personal firearms,” says Sandra McKay, MD, an associate professor of pediatrics who oversees the curriculum. “I demonstrate threading the cable up the pistol grip [on a handgun] and out the ejection port — the hole where a used bullet casing is ejected — and then into the lock so it can’t be fired.”
MGH trainees get to handle actual gun locks and learn how to provide the devices. “Before, I didn’t even know what a gun lock was or what it looked like. I certainly would never have thought to bring it up with patients,” says psychiatry intern Daniel Harris, MD, who took a training that’s required for residents in six specialties.
To help protect patients, students and residents also learn to identify those at risk of experiencing — or causing — firearm injuries, as well as circumstances that can increase those risks.
At UC Davis Health in Sacramento, California, for example, emergency medicine and general surgery residents study research related to children and guns. One notable experiment with 8- to 12-year-old boys found that though participating parents usually believed their child wouldn’t touch a gun, nearly half of those who found a hidden firearm went on to pull the trigger.
Older adults are another population that may require extra screening, educators say. If a patient is beginning to experience dementia, for example, it’s just as essential to query the family about firearm access as it is to raise concerns about driving.
And because suicide is the leading cause of firearm deaths, trainees learn which populations may be at increased risk: patients with a history of depression, victims of violence, veterans, and LGBTQ+ youth, among others.
If an at-risk patient wants to temporarily relinquish their firearm, trainees may also learn how to help with that. In California, for example, a friend or relative is allowed to temporarily store someone’s gun — provided certain requirements are met, says Nikia McFadden, MD, a UC Davis chief surgical resident who co-created the training there.
In some states, law enforcement officials also can temporarily remove a firearm if danger to oneself or others appears imminent. Brown students learn which states have these “red flag laws” and some differences among them, says Knopov.
Although such legal matters may seem at a remove from medical practice — physicians generally can’t petition for firearm removal but they can advise patients’ families, for example — Knopov considers them part of doctors’ preventive toolkit. After all, she says, “physicians often are the first people to identify that someone is at risk of harming themselves or others.”
For example, in a 2019 study of an urban emergency department, trainees who saw pediatric patients with suicidal or homicidal thoughts asked about firearm access in just 5% of cases.
A number of obstacles inhibit such conversations, but one of the most basic is that many doctors simply aren’t sure what to say.
“Students always learn to ask about things like alcohol use and sexual history, and we also want to help make it natural to ask about firearm safety,” says Knopov.
“This topic can be so politically charged,” she adds. “But we teach students that the conversation is not about political advocacy, and it’s not about getting patients to stop owning guns.”
In order to craft language that promotes respectful, culturally sensitive conversations, UTHealth Houston educators gathered input from firearm owners and sellers. McKay points to one takeaway: Say “firearm,” instead of “weapon,” since the latter may connote aggression.
UTHealth Houston trainees also learn not to ask patients if they own a firearm since such a question might make patients suspect an anti-gun bent. Instead, McKay advises, just ask if any firearms are stored safely.
“Students always learn to ask about things like alcohol use and sexual history, and we also want to help make it natural to ask about firearm safety."
Anita Knopov, MD
Warren Alpert Medical School of Brown University
But guidance for patient interactions is insufficiently valuable without the opportunity to apply it, so educators often use standardized patients to enact realistic scenarios.
In one UTHealth Houston workshop, internal medicine residents meet a simulated patient with increasing depression and a firearm at home. “In this situation, recommended counseling can include saying, ‘We need to adjust your medications. Is there someone who can hold your firearms temporarily while we do that?’” according to McKay.
And what if patients resist safety counseling? “We always emphasize that providers should meet patients where they are,” says McFadden.
Sometimes, patients may reject gun locks since they want quick access in an emergency, McFadden notes. “Instead of discounting that, we can encourage patients to consider possible implications of their decision, such as a child accessing the firearm. And we can ask about other ways to increase safety. Is there a safe that opens quickly, for example?”
MGH’s Harris says practice cases increased his empathy for patients who own firearms. “I never grew up around guns, but the training helped me understand that people who own firearms are not a monolith. They do so for many reasons, including not feeling safe in their neighborhoods,” he says.
Third-year Brown student Anneliese Mair greatly appreciates the opportunity to rehearse firearm-related interactions. “In some situations, such as the history of violence in a relationship, learning there’s a gun in the home can raise alarm bells for clinicians. It’s extremely important to learn how to handle such situations calmly before facing them out in the real world.”
“Every student, everywhere”
So far, research shows that firearm-related curricula increase students’ ability to communicate effectively about firearm safety. After one of UTHealth Houston’s workshops, for example, pediatric residents said they felt more comfortable counseling patients about firearms and actually did so more often than before.
Next up is spreading the word. “My goal is to expand our curriculum into a national model,” says Brown’s Knopov. “Each place could use it differently, but I’d like to have this topic be part of every student’s medical education, everywhere.”
One dissemination approach is to create online educational resources that any individual or institution can use. Stanford Medicine and the organization Scrubs Addressing the Firearm Epidemic provide a self-paced, three-module training on firearm injury prevention, for example.
“If I can help one person feel more comfortable talking about gun safety and save a life, I have done my job.”
Sandra McKay, MD
McGovern Medical School at UTHealth Houston
Meanwhile, educators at Cincinnati Children’s Hospital Medical Center (CCHMC) are taking a decidedly novel approach: creating avatars to help trainees practice gun-related patient encounters.
These virtual, on-screen actors respond in real time to trainee comments and come replete with appropriate body language and facial expressions. Their reactions appear thanks to prerecorded responses that a facilitator chooses via behind-the-scenes controls. “It’s sort of a Wizard of Oz approach,” says Joseph Real, MD, a CCHMC associate professor of pediatrics and one of the program’s co-creators.
Avatars make sense in part because one virtual reality package can be used at numerous institutions — and less expensively than standardized patients, says Real. The team has already started testing the program with CCHMC residents and is working on ways to share it with colleagues elsewhere.
UT’s McKay is excited about such efforts to educate trainees in skills central to helping prevent firearm injuries.
“This work is so important,” she says. “If we can support our trainees, then they can support their patients and help save lives. The whole goal is saving lives. If I can help one person feel more comfortable talking about gun safety and save a life, I have done my job.”
Editor's note: Given the growing number of gun deaths in the United States, the AAMC has compiled related resources in the AAMC Virtual Communities Network. Members are invited to add their best practices and resources to the bundle. Individuals can join the network and learn more.