Introduction

Firearm injury deaths in the USA are rising, and as of 2017, they represent 12.2 deaths per 100,000 populations for a total of 39,773 deaths in 2017. Firearm deaths now exceed motor vehicle crash deaths in the USA (11.9 deaths/100,000 population) [1]. We as healthcare professionals treat many of those injured and thus have a unique perspective on not only the pain, suffering, and medical resources required to treat resultant physical and emotional injuries, but we also have unique insight into strategies to prevent these injuries and deaths. We are charged with the health of our patients and thus with prevention of disease and injury, which threaten the health and well-being of those we care for. In order to address this public health crisis which affects us all, we need to develop a multifaceted strategy to decrease firearm injuries and deaths.

Over the past 50 years, the emergency healthcare community in the USA has developed and implemented a systematic approach to developing Emergency Medical Services (EMS), trauma, disaster, and emergency healthcare systems. The development and implementation of these systems can provide a model or framework to address other complex health problems. This systems-focused approach is based on five key principles: (1) be maximally inclusive with engagement of stakeholders, (2) create an ongoing dialog among these stakeholders focused on developing a consensus plan on what is the right thing to do for the patient or the population being served, (3) establish processes which ensure timely and structured cooperation, mutual respect, and communication, (4) develop infrastructure to collect actionable data which support quality improvement and research, and lastly, (5) cultivate a bias for action with a focus on implementing and hardwiring system improvements. This inclusive, consensus-based, yet action-oriented approach requires professionalism in all interactions with stated responsibility to the patient and to the community. This approach can achieve trust and leads to productive teams and durable solutions. These principles are generalizable to solving or effectively managing the complex challenge we now face in formulating and implementing effective firearm injury prevention [2••].

This systems approach is based on a public health model and requires engagement across disciplines and specialties, geographic regions, and philosophic differences. Building consensus requires a commitment to values of civility, professionalism, and mutual respect by all who participate. When applied to firearm injury prevention, the systems approach requires the expertise, leadership, and participation of all relevant stakeholders. To be effective and durable, this approach specifically requires the healthcare/public health community to thoughtfully and intentionally engage two groups with disproportionately high rates of firearm injury: firearm owners and members of vulnerable communities. Both of these communities have the knowledge and understanding to develop and lead constructive, pragmatic, and durable solutions. Unfortunately, from our vantage, both of these groups are sometimes stigmatized as the problem rather than commended as the path to the solution. Inclusion, engagement, and partnership with communities at risk for an adverse health outcome are core tenets of a public health approach. We believe this strategy has already been fruitful and with further resources will lead to improved focus on social determinants which create and potentiate the underlying cycle of violence while also increasing and improving safe firearm ownership.

An analogous, complex injury problem existed in our past – that of motor vehicular collision-related injuries and death – which was addressed as a public health crisis. A multifaceted, public health approach to vehicular injury prevention began in the 1960s and has resulted in significant decrease in motor vehicular-related deaths in the USA over several decades (Fig. 1). Roads were continuously reengineered, crash tests informed motor vehicle safety feature development, population-based research guided the development of safer automobiles, and legislation was enacted to encourage safe driver behavior. Safety advocates partnered with the public, almost all of whom were automobile drivers. Many effective strategies came from these partnerships. The strategy of “friends helping friends” approach was adopted to reduce drinking and driving. It is our belief that a similar public health approach to reduce firearm injuries and deaths can be equally effective.

Fig. 1
figure 1

All intentional injury (all mechanisms) vs. traffic related injury vs. intentional firearm injury (age adjusted)

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This review will begin with early efforts to reach consensus within our own professional organization, the American College of Surgeons (ACS), and then describe the extension of this approach to the broader medical and public health community, leveraging the results of actionable areas of agreement every step along the way while applying the principles outlined above.

The ACS Approach

The American College of Surgeons (ACS) Committee on Trauma (COT) has pursued a broadly inclusive strategy with a goal to develop a consensus approach to reduce firearm injuries and death in the USA [3•, 4, 5]. This strategy has included obtaining input utilizing several modalities to identify a broad spectrum of views and opinions. Multiple survey(s) of surgical groups, town hall and professional organization meetings, ACS COT Injury Prevention and Control Committee Meetings, interactions with the ACS Board of Regents and Board of Governors, local ACS Chapters, other trauma surgery organizations, and multiple small group/individual meetings with surgeons across the country were used to collect input. We utilized anonymous surveys to learn about the personal opinions of surgeons as well as their opinions about potential advocacy, research, and injury prevention initiatives that the ACS and other organizations could act on. Survey results were used to identify areas of consensus that could then be translated into actionable initiatives. We began by first surveying our own members beginning with trauma surgeons from the Committee on Trauma and other professional organizations, extending to the Board of Governors’ leadership of the ACS and then to the entire ACS membership (50,000 US surgeons) to better understand the views of our members on firearm ownership and approaches to advocacy, research and injury prevention [3, 4, 6].

We found that surgeons, similar to the general US population, differed significantly on their opinions regarding whether firearms are beneficial and a critical liberty versus those who felt that personal ownership of firearms was generally harmful [3, 4, 7••]. Despite these differing opinions on personal ownership of firearms, there was significant agreement that it was important to address this public health crisis. This approach resulted in a constructive dialog between those who differ regarding their opinions on the benefits of firearm ownership and personal liberty but who agree upon the critical importance of reducing injuries and deaths related to firearms. A Common American Narrative emerged, that of “Freedom with Responsibility”, which recognizes that firearm ownership is a liberty protected by the US Constitution and that violence is a major cause of preventable death and suffering. The Common American Narrative also recognizes that we can work together to make firearm ownership as safe as possible and that we need to understand and address the root causes of violence [7••].

Through ongoing dialog, we came to realize that firearm owners and the communities at risk of firearm injury are often approached as a part of the problem but less commonly approached as a part of the solution [8••]. We and others have called for a public health approach to the epidemic of firearm-associated injury and death and more specifically firearm violence [3, 9,10,11,12]. A key step that is an important ingredient of the public health approach is community engagement [13,14,15,16,17,18,19]. Strategies to achieve community engagement relating to public health interventions are recommended by major international public health organizations [13,14,15]. The degree of community engagement can make a significant difference in the efficacy or lack of efficacy of a public health program. As a specific example, if a trauma center’s injury prevention and outreach team wanted to implement a bicycle safety program, an important early step would be to engage bicycle riders to learn about and leverage their experience and expertise in the activity with the goal of making the prevention program as feasible and effective as possible [20••].

To help guide firearm injury prevention initiatives, we sought to engage firearm-owning surgeons through the development of a Firearm Strategy Team (FAST). Just as with surgery, engagement is a blend of science and art [13]. A good example of this type of engagement in the firearm injury prevention arena is Barber and colleagues’ work on suicide prevention through engagement of the firearm owner community, engaging them as “trusted messengers” to build community engagement [8]. They pioneered a “friends helping friends” approach to this engagement. To use another example that relates to bicycle safety, the individual bicycle rider is simply more receptive to a safety message from a bicycle enthusiast or representative from the bicycle community and generally much more receptive if the message comes from those who are supportive of bicycling. This is also true in medicine; surgeons are much more receptive to messages from their surgical colleagues and likewise for other specialists. This also applies to patients – critically injured trauma patients are more receptive to advice and counseling from trauma survivors who have been in a similar position, thus the basis of the employing a trauma survivors’ network [21]. Similarly, the FAST workgroup has been critical in informing strategies and messaging for firearm safety and injury prevention and has reached consensus on and published actionable initiatives [20••].

When we apply the principles of consensus-based system development, it is important to remember to engage stakeholder groups throughout the process from conceptualization to the development and implementation of actionable initiatives. Examples of actionable consensus informed initiatives that have been informed by ACS member surveys include advocating for federal funds to support research, educating and training healthcare workers to talk with patients, encouraging trauma centers to address the root causes of firearm injuries and death in the geographic areas they serve, and developing a research agenda to determine critical research questions that require an evidence-based answer to guide the development and implementation of effective injury prevention initiatives. By leveraging the network of over 560 ACS-verified trauma centers for implementation, firearm injury prevention initiatives can be widely disseminated and prevent significant numbers of firearm injuries and death.

Medical Summit: Building Consensus Across the Healthcare Community on a Public Health Approach

In order to address the complex public health challenge of reducing firearm injuries and death in the USA, we recognized the need to engage the entire healthcare and public health community. On February 10–11, 2019 the American College of Surgeons hosted a historic Medical Summit on firearm injury prevention that included leaders of 44 medical, public health, and injury prevention organizations along with the American Bar Association. The Medical Summit attendees met to share their organization’s efforts to address the public health challenge of increasing firearm deaths in the USA, with the goal to collaboratively work together to (1) identify opportunities for the medical community to reach a consensus-based, nonpartisan approach to firearm injury prevention, (2) discuss the key components of a public health approach and define interventions this group will support, and (3) develop consensus on actionable items for firearm injury prevention using the public health framework [2••].

The Medical Summit program featured experts from several disciplines and medical specialties and included an overview of the epidemiology of firearm injuries and death in the USA and discussion of the social determinants of health and structural violence. Gun violence was recognized as a complex biopsychosocial disease and as such warrants a public health approach. This approach involves four stages including (1) understanding the epidemiology, (2) injury prevention program development, (3) research to evaluate program outcomes, and (4) dissemination of successful programs. Gaps and opportunities in firearm injury prevention research were identified and the participating organizations provided an overview of their firearm injury prevention activities. The ACS reviewed its consensus-driven strategy and creation of the Firearm Strategy Team (FAST). Several injury prevention initiatives were reviewed, including safe storage, lethal means counseling, as well as hospital and community-based violence intervention/prevention programs. Current best practices to screen patients who are at risk of firearm injury or death, including those with mental health risk factors, were discussed. Culturally relevant public policy was noted as a critical component of a public health approach to reduce firearm injury and death in the USA. Haddon’s matrices of potential injury prevention strategies were constructed for suicide, intentional injury to others, and unintentional injuries [2••].

Forty-seven professional organizations including those that attended the Medical Summit for firearm injury prevention have subsequently endorsed nine consensus statementsFootnote 1:

  1. 1.

    Firearm injury in the USA is a public health crisis.

  2. 2.

    A comprehensive public health and medical approach is required to reduce death and disability from firearm injury.

  3. 3.

    Research is needed to better understand the root causes of violence, identify people at risk, and determine the most effective strategies for firearm injury prevention.

  4. 4.

    Federal and philanthropic research funding must be provided to match the burden of disease.

  5. 5.

    Engaging firearm owners and populations at risk is critical in developing programs and policies for firearm injury prevention.

  6. 6.

    Healthcare providers should be encouraged to counsel patients and families about firearm safety and safe storage. Educational and research efforts are needed to support appropriate culturally competent messaging.

  7. 7.

    Screening for the risk of depression, suicide, intimate partner violence, and interpersonal violence should be conducted across all healthcare settings and in certain high-risk populations (such as those with dementia). Comprehensive resources and interventions are needed to support patients and families identified as high risk for firearm injury and who have access to a firearm.

  8. 8.

    Hospitals and healthcare systems must genuinely engage the community in addressing the social determinants of disease, which contribute to structural violence in underserved communities.

  9. 9.

    Our professional organizations commit to working together and continuing to meet to ensure these statements lead to constructive actions that improve the health and well-being of our fellow Americans.

We believe the united approach of the medical and public health communities provides a promising path forward to tackle this complex problem.

Post-medical Summit: Mapping the Path Forward

Following the Medical Summit, we have continued to work together in advocacy, research, and program development and implementation. One example is the formation of a new strategy team known as I-Save: Improving Social Determinants to Attenuate ViolencE. This multidisciplinary group seeks to develop actionable strategies to address the social determinants of health that contribute to violence in our society. The I-SAVE team includes those who represent at-risk populations for firearm injury and death and multidisciplinary experts from across the country who are committed to developing actionable approaches to address this facet of this complex problem. This group is exploring approaches to investing in high-risk communities by leveraging hospitals, professional organizations, and healthcare systems; educating health care providers on the social determinants of health and health equity; implementing a trauma-informed approach in the care of victims of violence; and developing hospital and community-based violence intervention programs.

Other examples of continued collaboration, guided by Medical Summit consensus, include the formation of a 2-year ACS Firearm Injury Prevention Clinical Scholar, which is supported by the ACS, the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM), the Eastern Association for the Surgery of Trauma (EAST), American Association for the Surgery of Trauma (AAST), and Western Trauma Association (WTA). In addition, multiple research funding opportunities offered by AFFIRM, leveraging private donations in support of firearm injury prevention research. Collaboration continues in program development and implementation, research, and advocacy. Given the large number of organizations (47) that represent multiple medical and other specialties, the potential impact we have in working together to decrease firearm injuries and death is significant. If collaborative, actionable initiatives can be implemented and leveraged by these professional organizations, we can positively make a difference by decreasing firearm injuries and death in the USA. Additionally, healthcare systems and networks can play an important role in the prevention of firearm injury of millions of Americans.

Conclusion

While the problem of firearm injury and death in America may appear mired in the political debates regarding the risks and benefits of firearm ownership and personal liberty, we believe our experience has demonstrated that there is a path forward to address this crisis through a consensus-based, public health approach. Together we can reduce death and disability while preserving the rights of firearm owners.