Survey of the American College of Surgeons Board of Governors on firearm injury prevention: Consensus and opportunities

Firearm-related injuries and deaths represent a significant public health problem in the U.S. More than 17 percent of the overall burden of injury deaths are firearm-related, translating to an average of 32,529 firearm deaths per year since 2010—approximately the equivalent to deaths resulting from motor vehicle crashes or fall-related injuries.*

To address this public health challenge, the American College of Surgeons (ACS) Committee on Trauma (COT) sought to identify areas of agreement and disagreement within its ranks to better inform and guide injury prevention and advocacy strategies. The ACS COT Injury Prevention and Control Committee developed a 32-question survey to evaluate COT member attitudes and beliefs regarding firearms, firearm injuries, and potential policy approaches to firearm injury prevention. The survey was administered to U.S. COT members in 2016. The findings were presented to COT members at a 2016 Town Hall and they were presented at the American Association for the Surgery of Trauma (AAST) meeting in 2016, and subsequently published in the Journal of Trauma and Acute Care Surgery.^†

The ACS Board of Governors (B/G) sought to learn more about the opinions of U.S. ACS Governors regarding firearm injury and firearm injury prevention with the belief that the B/G is more representative of the ACS Fellowship than the COT. The Executive Committee of the B/G worked with the ACS COT leadership to identify a subset of the ACS COT survey questions for inclusion in the 2016 ACS annual B/G member survey. The annual B/G member survey has been conducted for more than 20 years, and in 2016, a total of 11 focused questions from the ACS COT survey were included. Two-thirds of the U.S. B/G members represent their state ACS chapters and one-third represent specialty societies. Our hypothesis was that the B/G survey results, which represent the opinions of surgeons from a range of surgical practice types, would help identify topical areas and initiatives where broader consensus could be reached.

Methods

The research protocol and survey instrument were submitted to the Institutional Review Board at Boston University School of Medicine, MA, and were determined to be exempt according to 45 CFR 46.101(b). The questionnaire was sent via e-mail to U.S. B/G members in 2016 using the SurveyMonkey cloud-based tool. Data were de-identified and analyzed using descriptive statistics, chi-square, Fisher’s exact test, and Mann-Whitney and Kruskal-Wallis tests; 0.05 were used for statistical significance using IBM Statistical Package for the Social Sciences Statistics Software version 21. In addition to the routine analysis of the B/G survey, the focus questions on firearm injury prevention were compared with responses to the COT survey. The results of the survey and the survey analysis were shared with the B/G during its joint meeting with the Board of Regents at Clinical Congress 2016.

Demographic results

A total of 187 of 218 Governors responded to the survey, for an overall response rate of 86 percent. Their de-identified responses comprised the cohort for analysis. At least one survey participant from 48 states and two U.S. territories responded. Results were extracted and analyzed by members of the Governors Survey Workgroup. A range of specialties was represented, including general surgery (20 percent); acute care general surgery (10 percent); trauma surgery (8 percent); surgical oncology (8 percent); breast surgery (7 percent); critical care surgery (7 percent); and colon and rectal surgery (7 percent). The remaining 33 percent of respondents were from different surgical specialties. The combination of general surgery, acute care, or trauma surgery accounted for 38 percent of respondents in the B/G survey in contrast to 81 percent in the COT member survey. When asked about the presence of one or more firearms in the home, 35 percent of B/G respondents answered in the affirmative, compared with 43 percent of COT member respondents.

Personal opinion question results

The B/G survey included two personal opinion questions regarding firearms, which also were part of the COT member survey. The first question sought the respondents’ opinion regarding the general benefit (or lack of benefit) of firearm ownership and their views on personal liberty and firearm ownership. The responses from the COT survey and the B/G survey were similar (see Table 1). A little more than half of both groups expressed the belief that personal firearm ownership is beneficial and an important liberty or a constitutional right. Conversely, about a third of both groups expressed the belief that personal ownership of firearms is harmful, and generally or critically limits personal liberty. Approximately 15 percent of both groups had no strong opinion either way.

Table 1. ACS COT and B/G Survey: Personal views on firearm ownership

B/G members were asked what level of priority the ACS should give to preventing firearm-related injuries. As depicted in Figure 1, this page, 77 percent of the Governors indicated that the ACS should make preventing firearm-related injuries the highest or a high priority, whereas 88 percent of the COT survey respondents said that reducing firearm injury should be a high or the highest priority of the ACS.

Figure 1. Level of priority the ACS should give to reducing gun-related injuries

ACS Advocacy and Health Policy efforts

Respondents to both the B/G and COT member surveys were asked to rate their opinion on whether the ACS should initiate efforts to advocate or support legislation in seven specific areas related to firearm injury prevention:

1. Mandatory background checks and license/permit for all firearm purchases, including those from authorized dealers, gun shows, or private sellers
2. Measures to prevent people with mental illness from purchasing firearms
3. Efforts to increase penalties for purchasers who provide guns to individuals illegally (straw purchasers) and dealers who sell firearms through illegal means or who bypass background checks
4. Preserve the right of physicians and health care providers to counsel their patients or the parents of their patients on safe firearm ownership
5. Identify and implement evidence-based injury prevention programs that decrease firearm injuries (in partnership with other professional organizations or independently)
6. Limit civilian access to ammunition designed for military or law enforcement use (that is, armor piercing, large magazine capacity)
7. Advocate for research funding to better understand gun violence and how to prevent it

Table 2 presents a direct comparison of responses from B/G and COT members to these seven initiatives, without respect to firearms in the home. The level of “strongly support or support” ranges from 74 to 93 percent among B/G participants and between 76 and 93 percent of COT survey participants.

Table 2. Views on advocacy and health policy topics

The responses from the ACS Governors and the COT members were statistically different in two key areas. These two questions concerned preserving the right of physicians to counsel patients or families on firearm injury prevention (B/G 74 percent; COT 91 percent); and priorities for research funding regarding firearm injury prevention (B/G 80 percent; COT 92 percent). Although statistically different, members of both the COT and the B/G clearly support these approaches, although they differ in the degree of support.

For the other five advocacy initiatives surveyed, the percentage difference between the B/G and COT responses was not statistically different. Despite the specialty differences between the COT and the B/G, the level of support for these other five advocacy initiatives was remarkably similar.

Effect of firearm ownership on results

Both the COT survey and the B/G survey results were also analyzed based on whether the respondents had a firearm in the home. This evaluation was done to explore how closely or differently these two groups may be with respect to attitudes and beliefs regarding potential policies or strategies to reduce firearm injury. We hypothesized that there would be differences based on the presence or absence of a firearm in the home.

Table 3 shows the responses of COT members based on whether the respondent had a firearm in the home. Although statistically different, in general, as a group, the respondents with firearms in the home are very supportive of most of the issues, with more than 70 percent of respondents supporting six of seven of the advocacy issues surveyed.

Table 3. ACS COT Survey: Policy support with and without firearm in home

Table 4 displays the data for B/G respondents by the presence or absence of a firearm in the home. In B/G respondents, there were statistical differences in five of the seven areas when analyzed by the presence or absence of a firearm in the home. Like the members of the COT, the Governors with firearms in their homes indicate more than 70 percent support for five of the seven policy questions surveyed.

Table 4. ACS B/G Survey: Policy support with and without a firearm in home

For both groups, it is clear that the most contentious question for those surgeons with versus those without firearms in the home is the policy of limiting civilian access to types of ammunition designed for military or law enforcement use (for example, armor piercing, large magazine capacity).

The following list summarizes and compares with the COT the total percentage of B/G respondents who support or strongly support each initiative, and compares this finding with those respondents with a firearm in their home who support or strongly support each of the seven policies surveyed.

1. 93 percent of the Governors support preventing people with mental illness from purchasing firearms (91 percent, COT). When examining responses of those with firearms in the home, 92 percent of B/G and 87 percent of COT members support this initiative.
2. 90 percent of Governors support mandatory background checks and license/permit for all firearm purchases including those from authorized dealers, gun shows, or private sales prior to purchase (86 percent, COT). When examining responses of those with firearms in the home, 83 percent of B/G and 72 percent of COT members support this initiative.
3. 90 percent of Governors support increased penalties for purchasers who provide guns to individuals illegally (straw purchasers) (92 percent, COT). When examining responses of those with firearms in the home, 84 percent of B/G and 85 percent of COT members support this initiative.
4. 87 percent of the Governors support identifying and implementing evidence-based injury prevention programs that decrease firearm injuries (93 percent, COT). When examining responses of those with firearms in the home, 78 percent of B/G and 87 percent of COT members support this initiative.
5. 80 percent of the Governors support making funds available for research on gun violence and how to prevent gun violence (92 percent, COT). When examining responses of those with firearms in the home, 67 percent of B/G and 82 percent of COT members support this initiative.
6. 76 percent of Governors support efforts to limit civilian access to types of ammunition designed for military or law enforcement use (76 percent, COT). When examining responses of those with firearms in the home, 51 percent of B/G and 54 percent of COT members support this initiative.
7. 74 percent of Governors support preserving the right of health care providers to counsel their patients on safe firearm ownership (91 percent, COT). When examining responses of those with firearms in the home, 75 percent of B/G and 84 percent of COT members support this initiative.

Key findings

The results of this survey demonstrate that ACS COT members and ACS B/G members are largely in agreement on firearm injury and firearm injury prevention. Both groups believe the ACS should assign a high or its highest priority to reducing firearm-related injuries. Between 50 to 55 percent of surgeons of both groups agree that firearm ownership is beneficial and is an important freedom or right. About 30 percent of both groups believe firearms are generally harmful and limit personal liberty, and about 15 percent have no strong opinion either way. Both groups have relatively polar views regarding firearm ownership, but both groups are similar with respect to the degree of polarization.

The results of these surveys also demonstrate significant agreement between the ACS COT and ACS B/G regarding the policies addressed in the survey, with most members of the two groups sharing their support for most of the policies surveyed. This general agreement persists when the survey answers from members of the two groups are analyzed according to the presence of firearm(s) in the home. Most surgeons and other health care professionals with firearms in their homes support every policy surveyed, and for at least five of the potential policies, there is consensus agreement between those with and those without firearms.

Next steps

The U.S. ACS Governors represent the spectrum of surgical specialties and are geographically diverse. The significant consensus among the B/G members and between the COT and B/G surveys is useful in our effort to work toward a better understanding of the views of ACS members.

Both survey tools were designed to create an accurate picture of where surgeons agree and where they disagree, and to facilitate a professional dialogue among the surgeons being surveyed. Both the B/G and the COT agree that any advocacy-related strategy should be based on respect for the opinions of all Fellows, particularly for those surgeons with minority views. The COT has been in touch with stakeholder groups representing multiple points of view with the goal of improving the dialogue around how best to reduce death and disability related to firearm injuries.

In the meantime, the COT is working to evaluate the best evidenced-based violence prevention and intervention programs that could be implemented through its network of ACS-verified trauma centers. The COT also is moving forward with advocacy for increasing funding for research on firearm injuries and developing strategies for effective counseling regarding firearm safety.

The results of these two surveys show that, although there is only about a 50 percent chance we agree on the benefits of firearm ownership, the odds are favorable that surgeons agree on most policies aimed at reducing firearm injury. This realization should be the basis for collegial, civil, and inclusive discourse on how best to proceed.

The B/G and the COT are committed to working together and to improving the quality of the conversation around how best to reduce firearm injury.

Acknowledgements

The authors would like to thank members of the Executive Committee of the B/G, the COT Executive Committee, and the COT Injury Prevention and Control Committee. The authors also would like to acknowledge the following (all MD, FACS): David B. Hoyt, ACS Executive Director; Patricia L. Turner, Director, ACS Division of Member Services; Michael F. Rotondo, Medical Director, ACS Trauma Programs; ACS Regents James K. Elsey, Beth H. Sutton; and Michael J. Zinner, Chair, Board of Regents; and Diana L. Farmer, Chair, B/G Executive Committee. The authors would also like to recognize ACS staff members and Trudy Lerer, Connecticut Children’s Medical Center, Hartford, for their support and guidance on this important initiative.

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*Centers for Disease Control and Prevention. National Center for Health Statistics. About underlying cause of death 1999–2014. Available at: http://wonder.cdc.gov/ucd-icd10.html. Accessed August 14, 2017.

^†Kuhls DA, Campbell BT, Burke PA, et al. Survey of American College of Surgeons Committee on Trauma members on firearm injury: Consensus and opportunities. J Trauma Acute Care Surg. 2017;82(5):877-886.