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Key Issues from the Workshop’s First Day

In the final session of the workshop’s first day, Thea James, an associate professor of emergency medicine and the associate chief medical officer, the vice president of mission, and the director of the Violence Intervention Advocacy Program at the Boston Medical Center, moderated a lengthy discussion with three panelists. The panelists were Patrick Carter, the assistant director of the Injury Prevention Center and an assistant professor of emergency medicine at the University of Michigan School of Medicine; Joseph Simonetti, a clinician investigator at the Veterans Health Administration’s (VHA’s) Rocky Mountain Mental Illness, Research, Education, and Clinical Center for Suicide Prevention and an assistant professor at the University of Colorado School of Medicine; and Daniel Webster, a Bloomberg professor of American health in violence prevention and the director of the Johns Hopkins–Baltimore Collaborative for Violence Reduction at the Johns Hopkins Bloomberg School of Public Health.

James began the session by remarking that the day’s discussions represented a paradigm shift in that they focused on looking at firearm violence and injuries in much the same way that other diseases are approached. However, she said, what still has to happen is for work on firearm violence and injury to focus on the root causes of this disorder with an eye on prevention, in what she termed an “enhanced medical model.” Other takeaways from the day’s discussions, she said, included the intersection of firearm violence and injuries with root causes in the community and the importance of identifying what needs to happen to stop injuries from happening in the first place; the importance of addressing behavioral health issues and giving providers the tools to assess risk; and the need for both

qualitative and quantitative research that will drive implementation and impact.

James said that many of the young male gunshot victims that come into Boston Medical Center’s Violence Intervention Advocacy Program have tattoos that reflect what these men feel about the hopelessness of their futures, with slogans such as “Born to be hated, dying to be loved,” or “Living is hard, dying is easy.” To provide some form of hope for these individuals, she said, the program focuses on providing avenues for these individuals to alter their quality of life by addressing the social determinants of health, including jobs and housing, and any behavioral health issues. The program also provides behavioral health services for family members and other people close to the victim.

GETTING HEALTH SYSTEMS INVOLVED

Turning to her first question, James asked the panelists for their ideas on how to convince health systems that they have a role to play in this space and how to be successful in preventing firearm injuries and fatalities, given the range of factors outside of health care that lead to firearm violence. Carter replied that health care systems have to focus on the value of the services they provide for their consumers, which requires knowing the community; the prevalence of disease, including firearm violence, in the community; and how to address that most successfully within the context of the community. At the same time, he said, it will be essential to help the clinical staff understand that efficacious programs to prevent violence can have a positive effect for their patients, similar to the success of other programs and prevention efforts for commonly treated diseases such as stroke, diabetes, and heart attack. Carter also referred to Stephen Hargarten’s call to think of firearm violence as a biopsychosocial disease. Carter said that, in his opinion, reframing firearm violence in terms of a disease model leads to a focus on addressing the underlying causes of the disease. For example, no emergency department would treat a patient who had a stroke without also addressing their underlying hypertension and smoking before sending them home. “To not address the issues that are putting patients at risk for violence and firearm-related outcomes should not be considered the standard of care, especially when it is the second leading cause of death for youth in this country,” Carter said.

Another reason for health care systems to engage in this problem is that prevention does have a financial benefit, both to society and health systems, he said. For example, one study showed that a single-session intervention delivered in the emergency department can reduce violence outcomes at a cost of less than $17 per violence event averted (Carter et al., 2016). James remarked that giving health systems an opportunity to have a social impact

and a return on investment is ideal, and Simonetti said that one reason that integrated health systems and the VHA are so interested in addressing firearm violence is that they often bear the financial burdens of treating spinal cord injuries, chronic posttraumatic stress disorder, and other long-term consequences of firearm injury. He said, too, that clinicians want training and materials allowing them to do a better job preventing firearm injuries and firearm-related suicide.

Simonetti said he believes that research has a huge role to play in incentivizing how health care systems adopt firearm prevention as part of their mission, not just because research funding will attract academic institutions to become more involved and not just because research is critical for determining whom to screen and what to do once at-risk individuals are identified. “It could also be important in making this everybody’s problem,” he said, pointing to the diversity of expertise and areas of interest represented by the attendees at the workshop. As an example, he cited work showing that about half the individuals who die by suicide have no diagnosed mental health or substance-related condition (Boggs et al., 2017, 2018), a fact that most primary care doctors do not know. He commented that firearm suicide is a tremendous problem among palliative care patients but that the conversation around suicide prevention in oncology is just beginning. “If we make this a problem for more people in the room and not just those in the emergency department, I think care will follow,” he said. Requiring that health systems address gun violence, or violence generally, as a requirement for certain types of certification could be a useful incentive, he added. No trauma center, for example, should be certified as such if it does not have a risk recidivism program with mandated mental health therapy in place. James said that the American College of Surgeons is exploring the possibility of requiring that interventions be in place for certification.

Webster commented on the different approaches that will be needed to address firearm violence and firearm suicide. In his opinion, he said, there are more opportunities to both screen for and intervene with suicide, and he said he is confident that health systems will respond to the challenge of reducing firearm-related suicide. He said that his doctoral dissertation research on how parents think about their children’s risk of firearm injury found that parents are “pretty much in complete denial that their children or teens might ever be suicidal,” which suggests that research on how health systems can get through to parents about the risks of adolescent suicides will have a positive impact. Health system response to more assaultive firearm violence will be more challenging, he said, though it might become more tractable if health systems were financed to prevent disease rather than to treat disease.

Webster said that he appreciates the optimism that firearm violence can be solved based on the nation’s successful work in reducing, for example, smoking and drunk driving. However, firearm violence is different in one

important way, he noted: people do not smoke or drink and drive because they think it will make them safer, whereas people decide to own guns because they believe a gun makes them safer. “Yes, we will have some lessons for things that we have done successfully in these other realms,” Webster said, “but we also have to recognize guns are unique and present a unique safety challenge.” This challenge is magnified, Simonetti added, by the fact that firearm injuries and death are low-probability events and people are generally bad at personalizing low-probability events.

When James asked Webster to comment on how he believes health care systems can engage with the community to reduce gun violence and death, Webster replied that the Cure Violence program, a public health intervention, is one approach that focuses on building relationships with credible messengers in the community who can help resolve conflicts and take other steps to reduce violence in the community. There have been some successes with this type of program, he said, adding that he believes they can be made even stronger, particularly with regard to providing better support for the staff of these programs. “I think we should rise to the challenge of the complexity of this problem and build on Cure Violence and other community models,” Webster said. Carter agreed that partnerships between a health care system and its community can be a powerful approach for addressing gun violence, and he said that work within the Michigan Youth Violence Prevention Center demonstrated that combining health care–focused behavioral interventions for violence (i.e., Project SYNC) with other multi-level social and community-based interventions can have a powerful effect on reducing violence within communities (Carter et al., 2016; Heinze et al., 2015). Other important steps health systems can take will be resolving how best to work and form cooperative relationships with law enforcement using approaches such as the Cardiff model, particularly in places where there is a police department that is not driven by evidence or oriented toward prevention; and understanding and addressing policies that create the conditions, such as the link between redlining and poor quality housing, that increase the risk of gun violence.

HELPING PROVIDERS WITH THE AFTERMATH OF GUN VIOLENCE

James turned the discussion to the subject of how to deal with the secondary trauma or vicarious trauma that providers at all levels can experience when dealing with the victims of firearm violence or suicide. Simonetti replied that the first thing health systems can do is to recognize there is an impact on providers and then create a safe space for providers to talk about their feelings and experiences. Carter suggested holding debriefings among staff after they have treated a trauma victim and agreed that creating a safe

space for staff to talk about their feelings is key. From some of the work he has done implementing efficacious violence prevention services within emergency department settings, he said, he has learned that providing staff with the tools to help their patients can serve as a way to address the feeling of hopelessness that often comes with treating large numbers of firearm violence victims. In one ongoing implementation project, Carter said, the nurses participated enthusiastically in the implementation of the program as it provided them a way to feel empowered to do something to address the problem of violence and gave them a way to be a part of the solution to stopping the cycle of violence in their community.

HELPING HEALTH SYSTEM LEADERS ACT

When asked what information would help institutional policy makers understand their role and what actions they need to take, Webster said that it is imperative to help health system leaders find motivation to prevent firearm violence rather than simply treat it. Local data will drive that transformation, Simonetti predicted. “Understanding your own patient population and the issues that affect the people coming in your door is motivating for many health care systems,” he said. It is also important, he added, to provide health care systems with effective interventions and strategies to deal with the problem coming through their door, which is where the research community plays a critical role.

For Webster, the key question that health system leaders need to ask is whether they want to “own” prevention of firearm violence and suicide and take responsibility for it. Today, when there is a homicide or suicide in the community that his institution serves, nobody blames the institution for failing to prevent those events, and, as a result, nobody at the institution feels an obligation to prevent firearm-related homicides, injuries, and suicides. “I would love to see a change in that where we all have shared responsibility for this problem and doing something about it,” Webster said.

The one exception to this abdication of responsibility, Simonetti said, is veteran suicide, which the Department of Veterans Affairs (VA) takes seriously and for which it accepts responsibility even though its health care system (the VHA) sees only 20 percent of the approximately 20 million U.S. veterans annually. As a result, the VA has started programs dealing with housing and unemployment, working with veterans in rural communities, and doing community-based research.

SHIFTING THE PARADIGM

James’s last question for the panel regarded what they would do to shift the paradigm of what is being done today in order to see an impact on gun

violence and injury. Webster said that Johns Hopkins, the largest private employer in Baltimore, is addressing one of the social determinants by hiring people from the community it serves who have been victims of gun violence. Simonetti said that the VA has developed a predictive model for identifying veterans who are the highest of high risk of attempting suicide and has targeted interventions for those who screen positive. The VA is also expanding work from one to three large rural communities with high veteran suicide rates to see how it can build a community-based infrastructure for suicide prevention. He said that enacting a population health approach in the community is challenging but that it will be important in moving to the next level of effectiveness. Carter agreed that a multilevel approach that partners health systems with communities offers the best opportunities for significant progress.

DISCUSSION

George Isham said that when he was on the Community Guide Task-force that looked at evidence for population-based interventions, one of his observations was that many of the successful programs for implementing change across populations were multicomponent interventions, and he said he suspects that the same will hold true for a topic as complex as firearm violence and death. Isham also reinforced the idea that there will be a role for both public and private institutions to get involved in addressing this issue, and he suggested thinking about the kind of conversations that could be carried out among the board members and senior management of a health system about responding to some of the community’s needs. He said that he has had success recruiting epidemiologists and other experts in his health system to develop relationships with senior leaders and influence the investments they make over time.

Isham then commented that there are lessons to learn from the Alliance of Community Health Plans’ successful implementation of evidence-based care across its large health system members. These lessons include

• Generate consensus among decision makers about what is important and where the focus will be.
• Put together teams of skilled people, adequate resources, and capabilities to address the problem.
• Educate and train staff and develop evidence-based processes.
• Make sure that there are data and information to characterize the problem and monitor progress to identify victories.
• Ensure that incentives are aligned in order to reduce or eliminate barriers.

Gregory Simon, referring to Webster’s and Simonetti’s comments on accountability, said he believes that there is a reasonable path of accountability that does not re-traumatize staff but also identifies what could have been done better at the last touch with a patient who later committed suicide. He also suggested calling out successes and not just failures. Rebecca Cunningham from the University of Michigan said that accountability will need metrics and incentives, just as there are metrics relating to, for example, care for children with asthma. Joel Fein from the University of Pennsylvania Perelman School of Medicine added that framing firearm violence as a health and public health issue should drive health systems to take responsibility for addressing this problem. In the role of responsible party, health systems can convene all of the stakeholders needed to truly address this problem in a multifactorial manner and provide much of the expertise and talent to do so.

An online participant asked the panelists if they have faced challenges to their research from firearm lobbyists. Webster said he has been doing firearm research for almost 28 years, and the paucity of research funds has not kept him from doing research, but it has affected the scope of his research, particularly research concerning more in-depth questions.

An unidentified workshop participant asked the panelists if there is a way to empower physicians to do something more outside of their work environment, such as serve as active spokespersons and advocates for patients, as part of a process of helping them heal from the trauma and hopelessness of caring for victims of firearm violence. Webster’s response was, “Absolutely. That is occurring, and it has occurred on any number of issues, but certainly for firearms.” In the aftermath of the Sandy Hook tragedy, he said, he was overwhelmed with people in his health system coming to him and asking what they can do to stop this senseless violence. “You have a voice. You have credibility. Use it,” he said. Health care practitioners, he added, have the ability to discuss firearm violence as a public health problem and take the politics out of the discussion.

Simonetti said that clinicians advocating for violence prevention programs within their emergency department or trauma center can have an impact both in terms of getting a program installed and alleviating some of the frustration and helplessness that clinicians on the front line are feeling today. “It has been my experience that people are hungry for this, especially if you are regularly treating patients with gunshot injuries and suicides,” Simonetti said. Carter agreed and pointed to the importance of involving the entire health care team in these efforts and employing technology so that the burden of screening and intervening does not fall totally on the backs of physicians.

On a final note, Simonetti said that clinicians can be successful in promoting actions in this space, both in their health care systems and the larger

community. “I think clinicians have a more powerful voice than they think they do, particularly when they group together,” he said. James agreed and added, “We should not constrain ourselves by what we think is possible.”