A Preclinical Medical School Curriculum on Firearm Violence to Develop Patient Counseling and Foundational Health Policy Skills.

BACKGROUND: Firearm violence is a unique public health crisis in the USA (US). A majority of U.S. physicians believe they should discuss firearm safety with patients. However, little education on firearm injury prevention and counseling exists in medical school. We sought to address this gap by creating a curriculum on firearm violence as a part of a required preclinical medical school course focused on health policy issues.
METHODS: The Kerns 6-step model for curriculum development was used to define the problem and assess learner needs. The two-hour small group session was co-authored by a student and faculty member to address the course theme of health policy as applied to firearm violence. The Issue-Attention Cycle, history of firearm policy, and US politics were incorporated from published literature, with a patient counseling role-play added in 2019.
RESULTS: The 'Current Case in Health Policy - Firearm Violence' small group was implemented in 2018 and 2019 for all first-year medical students. Of the 2018 student evaluations, 57% selected this small group as the most valuable in the course. In a follow-up survey in 2020, 78% of the respondents agreed that they felt more confident counseling patients on firearm safety following the role-play.
CONCLUSION: Students broadly endorsed the incorporation of firearm policy and counseling skills into medical education. This curriculum can be adapted for learners at all stages of training, especially given the limited exposure to this topic in medical education.

Introduction

In 2018, the shooting at Marjory Stoneman Douglas High School in Parkland, Florida, amplified existing discourse around firearm violence as a public health issue in the USA (US). In 2017, 39,773 people died from firearm-related injuries in the US, surpassing the number of deaths from motor-vehicle crashes (38,659) and alcohol (35,823) [1].

Studies across specialties have found that a majority of physicians believe they should be involved in reducing firearm injury, but few actually perform such interventions [2-4]. These results were echoed in a study of students at 16 medical schools, in which 84% of those surveyed indicated that it was at least somewhat important to discuss firearm storage and access with patients, but only 4% usually or always did so [5].

Despite demands to address firearm violence as a public health crisis by numerous professional organizations [6,7], medical education on firearms remains sparse. A 2016 systematic review of firearm safety education for medical trainees and providers found only four studies of such programs, exposing a need for further curricular development [8].

We created a curriculum for first-year medical students to address the public health crisis of firearm violence, while also teaching students how domestic policies and legislation influence the practice of medicine. The curriculum included space for students to discuss the personal impact of firearms and related legislation, and to practice patient counseling.

Materials and methods

In March 2018, we developed a curriculum incorporating the epidemic of firearm violence into Health and Society (H&S), a three-week required preclinical course for all first-year medical students at the University of California, San Francisco (UCSF). We used Kern’s 6-Step Method for medical curricular development to identify educational needs, objectives, and learning format [9]. The components of the Kern’s process were informed by previous student course evaluations for H&S, core competencies for medical students at our institution [10], and literature review of current curricula on firearm violence.

A first-year medical student with an interest in firearm violence prevention and a physician H&S course director co-authored a one-time, two-hour small group session (Appendix A). Students participated in groups of 10–15 with clinical/social sciences faculty or medical student teaching assistants as facilitators. Facilitators received an orientation that included content review, training on navigating difficult conversations that may arise in the context of the small group, as well as a Facilitator Guide (Appendix B) with key points and guidance on time per section to standardize implementation of the curriculum.

Learners completed required pre-readings on public health theory, epidemiological research, legislation history, and research compilations [11-14]. Optional pre-work included podcasts, videos, and first-person accounts [15-17]. Students also completed the American Medical Association’s online module ‘The Physician’s Role in Promoting Firearm Safety.’[18]

The small group had 4 sections: 1) Reflection on the role of firearms in students’ communities and personal lives, 2) Discussion of the Issue-Attention Cycle, a framework that describes the public’s response to societal issues with a series of five predictable stages [11], and its application to public health crises 3) Patient counseling role-play on firearm safety, and 4) Discussion of firearm regulation policy and legislation in the US. The small group student and facilitator guides are included as Appendices A and B.

Feedback on the initial curriculum in 2018 and the updated curriculum in 2019 was elicited through student evaluations of the entire H&S course. It is our institution’s practice to sample a subset of students for post-course evaluation to mitigate survey request fatigue. Accordingly, 49 students in 2018 and 51 students in 2019 were randomly assigned an H&S course evaluation within 2 weeks of completing the course, we also developed an optional, anonymous survey using Qualtrics survey software (Qualtrics; Provo, UT) administered in June 2020 as a one-year follow-up for the 2019 edition of the small group to assess student perceptions of the value of the curriculum and confidence in knowledge from learning objectives. The survey included Likert scale questions based on the learning objectives and a free response section for further comments (Appendix C). This survey was distributed to all of the students who participated in the 2019 course. Quantitative questions were analyzed using descriptive statistics.

Results

This curriculum was implemented in the 2018 H&S course for 151 students. The overall H&S course evaluation, covering all the content in the course, was distributed to 49 students and was completed by 47 students (96%). Of the respondents, 57% (n = 27) selected this small group as the most valuable of the sessions in the course. In qualitative comments, students indicated a desire to further practice firearm safety discussions with patients. This feedback led to the addition of the role-play activity in the current curriculum.

The updated curriculum was administered to 157 first-year medical students in 2019. The overall H&S course evaluation for 2019 was distributed to 51 students and was completed by 47 students (92%). In qualitative comments, students indicated that the small group was valuable and applicable to current events and that a background lecture given before the small group would be a helpful addition to the curriculum.

Of the 157 students from the 2019 curriculum who received the optional one-year follow-up survey in June 2020, 36 students responded (23%). The majority of students ‘strongly agreed’ or ‘agreed’ on the importance of physicians understanding the impact of firearm violence (92%) and indicated increased confidence in the ability to counsel patients on firearm safety (78%). The results are summarized in Table 1.

Table 1.

Survey of students 1 year after participation in the 2019 firearm curriculum (n = 36)

Statement	Response % (n)					Mean
	1	2	3	4	5
I believe it is important for physicians to understand the impact that firearm violence and related health policies can have on patients.	3% (1)	3% (1)	3% (1)	25% (9)	67% (24)	4.5
I understand the concept of the Issue-Attention Cycle and the implications that it has for solving a health policy issue, such as firearm regulation.	3% (1)	3% (1)	6% (2)	33% (12)	56% (20)	4.4
The ‘Current Case in Health Policy – Firearm Violence’ small group allowed me time and space to reflect on the impact that a health policy, specifically firearm regulation, has had on my own experiences.	6% (2)	3% (1)	14% (5)	56% (20)	22% (8)	3.9
I felt more confident in my ability to counsel a patient/family about firearm safety after practicing during a role play activity during this small group.	3% (1)	6% (2)	14% (5)	72% (26)	6% (2)	3.7
This small group influenced the way I think about firearm violence and related health policies and laws, including their potential impact on my patients.	6% (2)	11% (4)	11% (4)	56% (20)	17% (6)	3.7

: 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree

In free response comments from the 2020 survey, students stressed the importance of firearm safety in medical education. Students were also interested in applying the Issue-Attention Cycle policy framework to other public health crises, including police violence. Some also proposed improvements, including facilitation by content experts and education on harm reduction techniques.

Discussion

We created a small group curriculum for medical students that integrates a health policy framework with firearm access screening and counseling practice. We posit that starting conversations around firearms within peer groups helps to build comfort in discussing this potentially challenging issue with patients. We also argue that providing background on the policy framework and societal perceptions surrounding firearms better prepares students for injury prevention counseling. In response to student feedback highlighting the importance of translating didactic knowledge into practice, we modified the session to include a patient counseling role play in 2019.

We developed this curriculum for first-year, preclinical medical students. However, this small group could be easily incorporated as a didactic for clinical students on clerkships such as pediatrics or psychiatry, or used to serve more advanced resident trainees and practicing physicians, as these are relatively new topics in medical education. This curriculum could also be extended to include interprofessional health-care providers with modification of the role-play element.

The survey responses indicate that students believe it is important for physicians to understand the impact of firearm violence on their patients. This matches findings in the existing literature that most physicians view firearm violence as a public health issue [3,4,6,7]. Seventy-eight percent of respondents either agreed that the small group improved their confidence in firearm safety counseling. In the future, incorporating a session in which students practice their firearm counseling skills with standardized patients could further improve student confidence.

For the 2020 survey results, several limitations must be considered. We administered the evaluation survey over 1 year after the session. While this may influence the results due to recall bias, it provides insight into confidence about their knowledge from the curriculum. The 23% response rate limits the generalizability due to possible nonresponse bias. However, we believe that these findings can still provide valuable guidance for future curricular development, particularly given the limited published research on this topic to date.

Several comments in the survey responses expressed a desire to select content experts as small group facilitators. This may be challenging at institutions that do not have physicians or community members who specialize in firearm violence prevention. While content expertise is always valuable, we focused on the skill of facilitating challenging conversations that is applicable for educators across a variety of topics. Students also suggested adding a general lecture to the course regarding firearm violence prior to the small group, which may be a more feasible addition to the content across institutions.

Another potential challenge is the perception that discussing firearm safety is political or inappropriate for the medical school curriculum. We emphasize that reducing firearm injury is broadly supported by non-partisan physician organizations across specialties [2,4,7] and should be approached as a public health intervention. We are also fortunate that our institutional leadership supported our efforts to include these topics in the medical school curriculum and hope that our example will provide support to others who may face challenges from their administration. Furthermore, the general public appears open to physician counseling on firearms, as 66% of surveyed US adult participants in one study believed it to be ‘at least sometimes appropriate.’ [19] Future studies should explore these topics brought up in our survey comments to inform pedagogy and student response to controversial topics in medical education.

We also recognize that students with minority opinions may feel reticent to express themselves. We emphasize the importance of clear expectation-setting at the start and inviting a breadth of opinions since the patients we serve will have similarly diverse beliefs, supported by the above-noted study in which one-third of US adults did not think discussing firearms with a physician was appropriate [19].A larger group debrief could also be considered in subsequent versions of the curriculum.

We envision that the policy framework of this curriculum, the Issue-Attention Cycle, could be adapted to other public health issues like the impact of climate change, systemic racism, or police violence. Future iterations of the curriculum should also discuss the effects of the 2020 US Congressional appropriation bill, which granted $25 million to the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC) to study firearm injury prevention and represented the first federal funding of firearm research since 1996, during the final section of the small group [20].