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    The disease of gun violence

    As the nation reels from mass shootings in Texas, Ohio, and California, future doctors are learning about gun safety — how to promote it, how to screen for danger, and how to help devastated communities cope.

    crowd at night holding up their cellphones
    People hold up their phones in lieu of candles at an interfaith vigil for victims of a mass shooting, which left at least 20 people dead, on Aug. 4, 2019 in El Paso, Texas.
    Mario Tama/Getty Images

    Michael Bagg was a first-year medical student at McGovern Medical School at the University of Texas Health Science Center at Houston when a news alert popped up on his phone. Another mass shooting.

    On the night of Oct. 1, 2017, 1,100 bullets were fired into a crowd of concertgoers in Las Vegas, Nevada, leaving 58 dead and 851 injured.

    It was just the latest in a string of mass shootings, but at that moment, Bagg felt something more than the usual grief and devastation. He felt a sense of urgency.

    “I felt like I was getting numb to the frequency and started thinking about what I could do to make this problem better,” he says. “It’s not something that will be fixed overnight. But I thought about how I could impact my local bubble to move the needle a bit.”

    That’s when Bagg decided to approach his school’s administrators about incorporating gun safety issues into the curriculum.

    Bagg isn’t the only one who has felt called to act. In the last few years, gun safety has been woven into curricula at medical schools across the country, taught from multiple perspectives and angles. Medical schools are training students how to screen for gun safety in the home, treat a wound once the bullet hits the body, and help reeling communities deal with the aftermath of gun violence.

    In fact, the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM) has convened a working group to develop curricula to help educate future physicians about firearms safety. In addition to representatives from more than a dozen universities and the AAMC, the group also includes gun owners, researchers, and patient advocates.

    “Gun violence is America’s most preventable disease. I say that because it’s almost entirely preventable and the numbers of people affected are so high.”

    Judy Schaechter, MD, MBA
    University of Miami Leonard M. Miller School of Medicine

    The consensus among top medical organizations is that gun violence is a public health epidemic, and doctors and other health professionals could and should be on the frontlines to prevent it. To that end, the AAMC was one of more than 40 medical and injury prevention organizations that met in February 2019 at the American College of Surgeon’s Medical Summit on Firearm Injury Prevention to develop a comprehensive roadmap for tackling gun violence using a public health approach.

    “The reality is that as doctors, we’re going to be seeing a lot of those issues in the clinic. The main focus is letting patients know they can talk,” Bagg says. “We want to emphasize it’s not a political thing. It’s a public safety thing.”

    America’s most preventable disease

    While they dominate the news headlines, mass shootings are only a fraction of the gun violence problem. Since 1966, 1,196 people have died in mass shooting incidents, including 190 children. The shootings in El Paso, Texas; Dayton, Ohio; and Gilroy, California, are just the latest of these public tragedies.

    Far more common are firearms-related deaths and injuries. In 2019 alone, 8,793 people have died and 17,479 have been injured, according to Gun Violence Archive, a nonprofit that tracks all incidents of gun-related violence in the United States. In 2018, there were 14,769 deaths and 28,236 injuries due to gun violence.

    These figures strikingly do not include the 22,000 annual deaths due to suicide. And access to firearms makes suicide attempts that much more deadly. A study led by researchers at the Harvard School of Public Health found that suicide attempts with a gun are 42% more effective than suicides by any other means, including drug overdoses.

    “Gun violence is America’s most preventable disease,” says Judy Schaechter, MD, MBA, chair of the department of pediatrics at the University of Miami Leonard M. Miller School of Medicine. “I say that because it’s almost entirely preventable and the numbers of people affected are so high.”

    In 2012, she led a coalition against the Firearm Owners’ Privacy Act in Florida, which banned doctors from asking patients about the presence of guns in their homes. That law was eventually overturned.

    Schaechter regularly speaks to mostly second-year classes about gun safety. Among other issues, she talks to students about the epidemiology of bullet wounds and what socio-economic factors are involved in gun violence.

    “Gun safety has been on the students’ minds for a long time. It’s taken a nice collaboration between us and them to enhance what we do.”

    Reena Karani, MD, MHPE
    Icahn School of Medicine

    At the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, gun safety issues are addressed during various stages of the curriculum, says Lauren Block, MD, MPH, associate professor in the department of medicine. Second-year students learn to ask parents and older children about guns at home, third-year students in the pediatrics rotation again learn to screen patients for gun safety at home, and during the fourth year, the cohort of students going into pediatrics undertake a gun safety project.

    “We want to make a curriculum that, throughout medical school, is getting people aware of the physician role,” Block says.

    Students at the Icahn School of Medicine at Mount Sinai are trained in the first two years to take comprehensive social histories of their patients, which includes learning how to ask them about gun ownership and safe storage. They also hear a lecture from Christian Pean, MD, MS, whose brother was shot by an off-duty cop in a hospital.

    “Gun safety has been on the students’ minds for a long time,” says Reena Karani, MD, MHPE, senior associate dean for undergraduate medical education and curricular affairs at Icahn. “It’s taken a nice collaboration between us and them to enhance what we do.”

    Students promote changes in the curriculum

    At some schools, students have played a key role in constructing curricula that tackle gun violence. Not long after the Las Vegas shooting, Bagg and a fellow student approached Assistant Professor of Family Medicine at McGovern Medical School Rebecca Lunstroth, JD, MA, looking for guidance on how to build a class on gun issues. Together, they developed an elective course called Gun Violence and Physicians: What You Need to Know. The course addresses mental health, advocacy, public health, and conversations students and doctors might have inside the clinic with patients about safe storage.

    “Our goal is for participants to walk away from this class understanding the large-scale extent of the problem, the mental impact on both the patient and the physician, what happens when a bullet hits a body, how can you use your voice as a physician to make a difference, and how to talk to your patients about guns,” the course description states. “We understand that this is an issue where people have strong opinions and our goal is to avoid wading into the political debate regarding firearms.”

    The course is designed to equip future doctors to deal with the ramifications of gun violence without delving into politics, Lunstroth says.

    “I have to give 99 percent of the credit to the students,” Lunstroth says. “They encouraged us to meet unmet needs. Two students came to me and said can we do this, so I merely said what they needed to do and helped shape it.”

    Starting in the fall of 2018, the Miller School of Medicine also began incorporating gun safety into the curriculum for first-year students. Rather than a lecture, students receive cases they must determine how best to handle, with learning objectives at the end. The cases include issues of gun access and storage.

    This addition to the program is the brainchild of two third-year students, Maxwell Presser and Anjali Sarver. They came up with the plan and presented it to the dean, and the students are currently working on a component for third-year students on preventing gun violence.

    “We were able to get the deans on board relatively easily and that is really promising,” Presser says. “There really is a role for students to be involved in what the curriculum looks like.”

    Awaken the spirit of inquiry

    Washington University School of Medicine in St. Louis also weaves gun safety into the curriculum across all four years, with a program called the Anatomy of Gun Violence. Laurie Punch, MD, trauma surgeon and associate professor of surgery, helped spearhead the effort.

    “The idea that I, as a trauma surgeon, had is to help students and residents understand gun violence as a disease that has a complex anatomy,” Punch says.

    Punch lectures to classes on patterns of physical injury, community experience, policy, and the role of the provider.

    She also addresses the risk of suicide by guns, as she has personally known three physicians who have taken their lives.

    “The idea that I, as a trauma surgeon, had is to help students and residents understand gun violence as a disease that has a complex anatomy.”

    Laurie Punch, MD
    Washington University School of Medicine

    Punch says one of the challenges is to make the issue real for students and residents. To achieve this, Punch formed a panel for first-year residents that included a survivor of gun violence and a mother who had lost her son to gun violence.

    According to Punch, there are four primary responsibilities physicians have when it comes to gun violence: 1) They need to provide excellent clinical care; 2) They need to do it in a way that’s community-responsive, trauma-informed, and patient-centered; 3) They need to be aware of the ways policy can influence patients; and 4) They need to be aware of their own vulnerability to firearm injury.

    But Punch emphasizes the importance of including the issue in already existing classes, rather than as an elective add-on.

    “I’ve tried to integrate it into what’s already there so the relevance is clear and it’s not dismissible,” Punch says. “It’s important to awaken the spirit of inquiry in these students. You don’t know what bright mind sitting in the room will bring change.”