Firearm injuries claimed the lives of 30,694 Americans in 2005, a death rate of 10.37 per 100,000 people. The vast majority of these deaths were suicides (56%) or homicides (41%) (1). Among major Western countries, the United States has the highest rate of firearm suicide and homicide, as well as the highest rate of gun ownership (40% of U.S. households) (2). Household firearm ownership has been linked to an increased risk of violent death among household members. In fact, access to firearms in the home is associated with a 17-fold increase in the risk of suicide by firearms and doubles the risk of firearm homicides (3). A recent analysis of the National Violent Death Reporting System found that firearms were used in 51% of all suicide deaths and 66% of all homicides (4). The financial losses from firearm injuries have been estimated to exceed $100 billion annually (direct medical costs of $2 billion and indirect costs of $98 billion each year) (5). The surge in firearm-related morbidities and mortalities in recent times has attracted the attention of health care providers and medical societies alike (6–10). Family physicians, emergency medicine physicians, orthopedic surgeons, internal medicine physicians, and pediatricians have all provided position statements and supportive training for residency firearm trauma. Every encounter with a health care provider is now seen as a unique opportunity to promote health and to counsel patients on effective morbidity and mortality prevention strategies, including anticipatory guidance on firearm safety.
Psychiatrists have unique opportunities for preventing firearm injuries to their patients and to themselves. First, there is increasing evidence regarding a relationship among mental health, gun access, gun storage practices, and firearm injury (11–14). Second, health professionals from primary care specialties tend to seek evaluation from or refer patients with suicidal or homicidal tendencies to psychiatrists. In addition to patients harming themselves with firearms, the potential is significant for psychiatrists to be attacked by patients. In one study of psychiatric residency training, up to 65% of residents were physically assaulted by patients (15). An outpatient survey found that 32 of 92 psychiatrists (35%) reported being seriously assaulted by patients (knife or gun used) and 59 (64%) reported less serious assaults (16). The most common malpractice claim against psychiatrists is wrongful death, primarily failure to properly evaluate the risk of suicide (17). Psychiatrists have long been active in addressing medication-related suicides. Addressing firearm accessibility is a natural extension of current psychiatric practices of means restrictions—in this case, the means with the highest case fatality ratio: firearms. This evaluation needs to include inquiry into patients’ access to guns. In the future, this type of liability will likely extend into homicidal risk and firearm assessment.
However, findings from a recent study indicate that psychiatrists are seldom involved in providing anticipatory guidance to patients concerning firearm-related injuries, even among suicidal patients (18). Apart from assuming that patients do not need firearm safety counseling, the other most prominent reason reported by psychiatrists for not providing firearm safety guidance was “lack of expertise” on the topic (18).
Level of professional expertise correlates with training received, and currently there is a strong consensus on the importance of having an integrated approach throughout the continuum of medical education to change the attitudes and practices of residents and their mentors regarding violence prevention. The American Medical Association’s (AMA) Liaison Committee on Medical Education (LCME) (19) recently released an update of curricular mandates in medical education, which stated, “The curriculum must prepare students for their role in addressing the medical consequences of common societal problems, for example, providing instruction in the diagnosis, prevention, appropriate reporting, and treatment of violence and abuse” (p. 1). Thus, the purpose of this study was to examine the extent to which psychiatric residency programs train future psychiatrists to be agents of change in relation to firearm injury prevention and control of firearm-related violence. Through a national survey of psychiatric residency directors, answers to the following questions were sought: What proportion of psychiatric residency programs provide formal training to residents regarding firearm injury prevention? What are the perceived benefits and barriers to offering such training? Do psychiatric residency program directors perceive that their residents would be able to address firearm injury prevention issues if requested by their patients? Do psychiatric residency program directors perceive that patients would see psychiatrists as an appropriate source of information on firearm safety and accept relevant anticipatory guidance?
The membership roster of the American Association of Directors of Psychiatric Residency Training (AADPRT) and the AMA’s Fellowship and Residency Interactive Database (FREIDA) were used to identify the entire population of U.S. psychiatric residency program directors (N=179) (20). The names and mailing addresses of current program directors were verified by telephone prior to data collection.
We used comprehensive review of the empirical literature on physicians’ training regarding firearm injury prevention to develop a questionnaire with adequate face validity. The questionnaire was subsequently sent to a panel of five experts in survey research and firearms, including researchers at the Centers for Disease Control and Prevention, to establish content validity. Minor wording changes were incorporated based on the reviewers’ comments. The final questionnaire consisted of 20 items designed to assess program directors’ perceptions and beliefs regarding firearm injury prevention training. The theoretical foundation for the survey included the main component of the Transtheoretical Model, Stages of Change (i.e., precontemplation, contemplation, preparation, action, and maintenance) in relation to providing formal training on firearm injury prevention (21), and the two key components of the Health Belief Model (i.e., perceived barriers and benefits to providing firearm injury prevention training to residents) (22). Respondents rated their level of agreement with the items using Likert-type (endorsement and frequency) scales as well as multiple response formats. Demographic and background items were included for descriptive purposes.
In the fall of 2008, we employed a three-wave mailing procedure, including a variety of published techniques to increase the response rate (e.g., limiting the survey to four pages in length, providing a $2 incentive for participation, using personalized cover letters, and including self-addressed stamped return envelopes) (23, 24). This procedure was approved by the University Human Subject’s Institutional Review Board.
We analyzed the data using SPSS version 16.0. Level of significance was set a priori at p<0.05. Frequency distributions were tallied on categorical variables. We calculated descriptive statistics to describe item responses. We calculated cross-tabulations using Pearson’s chi-square tests, and used independent samples t tests to assess mean differences.
One hundred fifteen completed surveys were received (return rate =64.2%). The majority of respondents were Caucasian (85%), male (71%), 40–59 years old (67%), and employed full-time by the residency program (82%). The few directors (18%) who owned a gun reported that they had received it as an inheritance from parents or grandparents and used it for personal protection, hunting, or gun collection purposes. The majority of graduates from the responding residencies ended up working in independent practice (34%), with government agencies (17%), or in hospital-based programs (17%) (Table 1).
Current Attitudes and Practices in Training Residents on Firearm Injury Prevention
Program directors were asked to identify the firearm injury prevention training practices that characterized their program (Stages of Change). The majority (79%, n=91) reported that they had not seriously thought about providing firearm injury prevention training to their residents (precontemplation stage). While 11% (n=13) indicated that they had been training residents in firearm injury prevention for more than 1 year (maintenance stage), another 4% (n=5) were willing to discuss firearm injury prevention with residents only if the residents requested such information/training. A small proportion of directors (4%, n=5) reported that they had been seriously discussing the possibility of including firearm injury prevention training in the future (contemplation stage). Few directors (2%, n=2) reported that they had been training residents in firearm injury prevention issues for less than 1 year (action stage).
Program directors were asked to report their current practices in routine screening of patients for firearm ownership. More than half (55%, n=63) reported that they routinely screened their patients for firearm ownership, and slightly more than one-third of the directors (38%, n=44) reported that they did not routinely screen patients for firearm ownership. The remaining 7% (n=8) reported that they were not sure of their residency’s screening practices.
Perceived Benefits and Barriers to Providing Firearm Injury Prevention Training
Program directors were asked to identify the potential benefits and barriers to providing firearm injury prevention training to their residents (Table 2). The four most important perceived benefits were “increases safety of practicing psychiatrists” (57%), “reduces mortality from firearm suicides by patients and/or family members” (55%), “reduces mortality from firearm homicides by patients and/or family members” (51%), and “increases attention by mental health clinics toward firearm trauma prevention” (48%). The 10 potential benefits of providing firearm injury prevention training were summed to create a training benefit subscale score (potential range=0 to 10). The perceived benefits score for programs that provided firearm injury prevention training to residents (mean=2.85 [SD=2.20]) was not significantly different from the score of programs that did not provide such training (mean=3.17 [SD=2.53]).
The four most important barriers to providing firearm injury prevention training to residents were “lack of standardized teaching material for training the residents” (50%), “lack of faculty expertise on firearm issues in our residency training program” (49%), “lack of existing guidelines for training residents on firearm issues” (47%), and “no guidelines are provided by APA or ACGME approved curriculum competencies” (42%). The 14 perceived barrier items were summed to create a training barrier subscale score (potential range=0 to 14). The mean number of perceived barriers for programs that did not provide any form of firearm injury prevention training (mean=2.94 [SD=1.94]) was significantly higher (t=2.79, df=113, p<0.006) than the mean score for programs that provided some form of that training (mean=1.78 [SD=1.77]). It should be noted that none of the programs identified numerous (seven or more) barriers to implementing such training.
The directors were also requested to quantify the average didactic time spent on firearm injury prevention training over the entire duration of residency training, including seminars, rotations, journal clubs, and other training. The mean amount of time spent was 0.88 hours (SD=3.12), with a minimum of 0 hours (87 programs) and a maximum of 30 hours (one program).
Perceptions of Firearm Injury Prevention Activities
More than half of the program directors agreed that APA should provide guidelines on specific curriculum topics regarding firearm injury prevention (62%, n=71) and that patients would accept their psychiatrist providing anticipatory guidance on firearm safety (55%, n=63) (Table 3). Almost half of the directors (49%, n=56) agreed that the residents in their programs did not expect the residency training faculty to discuss firearm injury prevention issues. Over one-third of the program directors (39%, n=45) agreed that patients would view psychiatrists as an appropriate source of information regarding firearm safety.
Program directors were asked to assess whether their residents would be able to address issues of firearm injury prevention if requested by patients. A plurality of directors (30%, n=34) agreed that their residents would not be able to address such issues. Another 29% (n=33) were unsure of their residents’ ability in this area. When asked to provide an opinion, 63% of program directors (n=73) disagreed that firearm control is more of an ideology and partisanship issue than a serious mental health issue. The remaining directors either agreed (14%) or were unsure (23%, n=26).
Firearm Injury Prevention Topics Covered In the Residency Curriculum
Finally, directors were asked to identify which of 13 potential training topics on firearm injury prevention were covered in their programs if they offered such training. An “other” option was also listed. Three-fourths (76%, n=87) reported that they did not provide formal training on firearm injury prevention. The remaining directors (24%, n=28) reported that the three most important topics covered were “role of firearms in suicides” (23%, n=26), “directly asking patients about access to and ownership of firearms” (22%, n=25), and “role of firearms in homicides” (16%, n=18). The only other topics which had at least 5% responses were “safe storage of firearms” (8%, n=9) and “firearm risks in the workplace” (7%, n=8).
Programs were divided into two groups based on whether they provided (24%, n=28) or did not provide (76%, n=87) some form of firearm injury prevention training. These groups were then compared to determine whether several independent variables were associated with the likelihood that firearm injury prevention training was offered. Programs that provided firearm injury prevention training did not differ significantly from programs that did not provide such training based on the number of residents per program (mean=26.32 [SD=13.14] compared with mean=28.10 [SD=13.27], respectively). Thus, the size of a given residency program was not associated with the likelihood that formal firearm injury prevention was offered. Second, the groups were compared based on the duration of the residency program director’s employment. It was assumed that more recently appointed directors might have been personally trained regarding firearm injury and, if so, would more likely push to have the topic covered in their residency program. Programs that provided firearm injury prevention training did not differ significantly from programs that did not provide such training based on the duration of the director’s employment (mean=6.85 years [SD=6.65] compared with mean=6.52 years [SD=7.10], respectively).
Psychiatrists are uniquely positioned as medical professionals who specialize in health problems of the mentally ill to help prevent the premature death of these patients. As one form of premature death, suicide is usually perceived as a tremendous affront to psychiatrists’ sense of competence and professional status. Thus, as previously noted, the American Association of Directors of Psychiatric Residency Training (AADPRT) and APA, in collaboration with the American Association of Suicidology (AAS), should develop curricular guidelines to help reduce morbidity and mortality associated with firearms, the leading method of intentionally killing oneself or another (25).
Three-fourths of practicing psychiatrists do not have a routine system for identifying patients who own or have access to firearms (18). Additionally, almost half of practicing psychiatrists have never seriously thought about discussing firearm issues with their patients. Yet, psychiatrists who are provided with information on firearms are much more likely to be involved in anticipatory guidance regarding firearms (18). Thus, it is especially disconcerting to find that almost four out of five psychiatric residency directors in the current study reported that they had not seriously thought about providing firearm injury prevention training to their residents, with a median of 0 hours of formal training. The directors did not indicate that they faced numerous barriers to providing such training. Thus, the lack of urgency or perceived relevance to providing such training to residents seems to maintain the inertia of most residency programs toward violence risk assessment, especially as it relates to firearms. Recognition of the fact that systematic training in violence risk assessment leads to improvement in psychiatrists’ risk management plans should help provide the empirical evidence that would result in such efforts having high priority in residency programs (26).
A study of adults’ perceptions of physicians’ advice with regard to not keeping guns in the home found that 47% claimed they would follow such advice (27). An additional 37% indicated that they would seriously think about such advice from a physician, and only 6% indicated they would ignore or be offended by such advice. A more recent study with pediatricians found that parental counseling regarding the need to store guns unloaded and locked away resulted in substantial compliance (68% after 6 months) by parents (28). Additionally, when psychiatrists are provided with information on firearms, they are significantly more likely to be involved in anticipatory guidance regarding firearm safety (18). Thus, if residency programs trained residents in anticipatory guidance on firearms, this might help reduce firearm morbidity and mortality.
A brief clinical intervention that could be effective in identifying every patient who has access to firearms, advising these patients to remove firearms from their premises, and offering alternative forms of personal protection could be based on the 5 As Theory (ask, advise, assess, assist, and arrange) (29). Psychiatrists may want to work with their staff members to deliver the last two or three As if they perceive this brief intervention as intrusive on their time.
The findings of this study should be interpreted in light of its potential limitations. First, the response rate of 64% was adequate. However, almost two in five directors did not respond. If nonrespondents had different practices and perceptions than respondents regarding anticipatory guidance on firearm safety, a potential threat to the internal validity of the results would exist. Second, because the data were collected by self-report, some directors may have answered some questions in a socially desirable manner. This seems highly unlikely, however, because the vast majority of directors indicated that they had not seriously thought about providing such training. Finally, the questionnaire items all had closed-format responses. This could have been a threat to the internal validity of the findings to the extent that important items or response options were not included on the questionnaire. This too was a diminished threat because many of the items included an “other (please identify)” option.
At the time of submission, the authors reported no competing interests.