Rebecca Cunningham is a Professor in the University of Michigan Department of Emergency Medicine, and the Interim Vice President for Research in the U-M Office of Research. She is the director of CDC funded University of Michigan Injury Prevention Center, and the principal investigator of the Firearm Safety Among Children and Teens Consortium (FACTS). In this interview with Bailee Jacobsen, a second-year Emergency Medicine resident at Loyola University Medical Center, she shares insights from her career researching the prevention of injury in youth.

Edited by Kian Preston-Suni

How did you initially become interested in Social EM, particularly injury prevention?

I think my interest is really two-fold. One, in EM, we take care of a lot of people with injuries and at a certain point pretty early on in my residency I realized I was really interested in figuring out how people got into our trauma bays and emergency departments and what we could do to prevent it. There is so little we can do sometimes once they are there and having life altering outcomes. In the public health model, a classic example is you can keep pulling people out of the water but at some point you need to go to the front of the bridge and realize why people are jumping off and stop it there. 

Also, broadly, in terms of injury and violence, growing up in my house there was a fair amount of interaction with domestic violence in my family. That was a big motivator for me over the years in terms of understanding violence and the impact on families, and what the role of society and our health system is in prevention and helping to intervene.

A lot of your research is focused on children and youth. What drew your interest to this specific population?

The leading causes of death of adolescents and children are all related to injury. It is really an understudied, broadly viewed topic. For a lot of providers, injuries are bread and butter, and we tend to focus on things that are less common and more rare, as opposed to routine things such as car crashes and gun injuries. Quite frankly we see those all the time. Adolescence is a time that if we can prevent the trajectory from happening, especially in violence prevention, it is a time of great impact to be able to make those changes. So intervening with an adolescent or young adult that is becoming involved in violence or has had some interaction, there is an awful lot that can be done at that point to correct the course. Not that this can’t be done later in adulthood, but there is a different set of challenges there. Kind of back to the idea of working upstream, if we can help get people out of violence earlier on, we may be able to make a greater impact with less resources.

What do you feel are some of the unique differences between children and youth and the adult population in terms of gun violence and injury prevention?

In terms of firearms, adolescents are different than their adult counterparts in that their constitutional rights are different, and in the ability to legally own firearms. And, developmentally they are a unique population in terms of the time period for violence. Violence often peaks, regardless of whether firearm violence or not, in late adolescence and early adulthood between the ages of 14-24. These are key opportune times. After that, adults tend to either mature out of those responses or move out of the social situations that put them at highest risk, or put them on a path where individuals are more and more engaged with the path of violence and at that point often become involved with the criminal justice system. Youth is a time period where there is a lot of opportunity because of these big changes happening, that small course corrections can have a big impact. 

In terms of firearms, our group is working on any number of things, including some very basic things like: Why do teenagers carry guns? What motivates them to carry them? How many days do kids carry guns? In many surveys, the average percent of youth that have carried guns has been up to 50-70%, does that mean they are carrying them every day? Do they carry them to school? What motivates them to carry it one day vs another day? The reasons that youth carry guns are different than their adult counterparts, and need to be considered individually.

In terms of injury broadly: The other reason we have spent time looking at adolescents specifically in the emergency department in regards to prevention, is this age group tends to not be as involved with their pediatrician anymore and are not necessarily sick enough to be regularly engaged in primary care. So where do they go in our country? They go to the ER. So we are the people who interact often with adolescents and college age individuals. That is a real opportunity for us from a public health and social standpoint to help them with what can be healthy for their lives, and the biggest risks for that age group is injury. 

Do you have any particular techniques for talking to young adults and adolescents about risk factors and for screening for injury prevention in the ED?

We developed a theoretically based program called SafERteens. The website is safERteens.org and is based on a study that was replicated in multiple large-funded RCTs that is specifically geared toward preventing violence. We have done both universal prevention, all adolescents coming to an ED in a high-risk neighborhood, and also selected intervention to adolescents that come in with specific risks such as adolescents that have had a fight or some violence in the past 6 months or year. We created a motivational interview based, 30-minute counseling session during their time in the department, outside of their clinical care in the ED, and focused on how to keep them safer when they were discharged from the ER. Multiple studies showed that this intervention decreased their violence over the next 12 months significantly. The cost effectiveness studies we did showed that this intervention cost less than a bag of IV saline in totality. 

In kids that age, the biggest risk for death they have when they leave the ED is violence. We spend a lot of time in the ED with adolescents and their families counseling on things like inhalers, and yet we are often not spending a lot of time talking about their biggest risk for when they leave the ED which is how they are going to stay safe from the violence that is going on in their lives and families.

In this project, how were you performing the screening and interventions? Were EM providers administering the screening?

No, we were using iPads with confidential questionnaires. Interventions were originally done with research staff and eventually transitioned to hospital staff, but not with physicians. I believe that providers do not have the time for this sort of intervention. Child health and social workers have been involved in the interventions, and we have trained multiple individuals to perform these interventions successfully.

What do you see as some of the biggest barriers to implementing screening for injury risk in adolescents?

I think the will of the ED for seeing their role beyond that of acute care provision and to see themselves as part of a system approach. This is one of the only evidence based violence prevention programs out there for emergency departments.  

What are some of your biggest takeaways from your research thus far? Have there been any things or conclusions that you have that have surprised you?

One, there was some concern that kids, teens, and adults would not want to talk about the violence that was going on in their lives, that they would think it was too rude to ask, or they would not give straight answers. We found this not to be true. When people are asked questions non-judgmentally, confidentially, and in a structured format people were incredibly interested, willing, and grateful that somebody was asking them about this. The kids in particular that were witnessing and watching a lot of violence did not have anyone that was helping them process this or think about how to be safe from it. Many times they are incredibly grateful to talk about it and express their fears for their own safety. They may be there for abdominal pain or something else, but that is also a big problem for them and they are very willing to talk about it. 

Another thing that is most notable, especially in the ED, we have done longitudinal studies following children after they leave the ED after a violent injury. The death rates and readmission rates are stunningly high. It makes it feel almost unethical to do an observational study anymore when you realize what happens when we “treat and street” kids with minor violence without intervening. Their rates of re-injury and gun violence are really high and the health and trauma system are places that have that interaction and can intervene before this. Some methods to aid young investigators in following outcomes from the ER are found here https://www.ncbi.nlm.nih.gov/pubmed/30381864

Are there any current projects that you are currently working on that you are excited about?

Yes! I am the PI of the FACTS consortium right now (website: www.childfirearmsafety.org) and the goal of this project is to bring a cohort of people together in order to study firearm injury prevention in this age group. We are helping build the capacity and the research knowledge up and we are incredibly proud and honored to move the field forward. We need to get back to the point where we “take back the F word” and can talk about Firearm safety again. With the news that congress is now allocating funding specifically for this research, we need young, smart EM physicians to focus their time and energy on this.

What do you think are the biggest topics in firearm injury research that need to be addressed in future research?

We published in May 2019, the 26 most important questions and areas to be addressed for firearm safety. (This article provides) a research agenda and really a roadmap for people interested in research in the field. This is published in JAMA pediatrics (link: https://jamanetwork.com/journals/jamapediatrics/article-abstract/2734986)

How do you address some of the stigma and divisiveness that can surround the topic of gun violence?

First of all, we have to normalize it. I encourage people to talk about it a lot. There was a time 40 years ago that people would not talk about breast cancer either because it was too uncomfortable. Culturally, we need to start talking about it, otherwise we won’t get anywhere.

Second, I talk to people often that are way on one side or the other of the spectrum surrounding this topic, and I think focusing on common ground is the most important thing. The thing that everyone can agree on, regardless of the solution, is that we need to have less deaths by gun. How we get there can be a matter of debate, but we need to have that as a common goal. Once we have that as a common goal, then we can talk about how to make that happen. 

Where do you ideally envision the field of injury prevention, particularly gun violence, in 5-10 years?

This is the infancy of trying to figure out what works on this topic and what the questions are, and the whole field is in the process of getting rebuilt. I think the analogy to this would be the car safety in its infancy in the 1960s. We still had children falling out the back of car windows because they weren’t restrained, there were no airbags, etc. The field needs to move the way that other fields of injury prevention have moved in the past. The path is exactly the same, whether it be car safety, fire safety, drowning safety, etc. There is a conceptual framework for injury prevention, firearms really aren’t different from that. We need to take the public health approach. 

Is there anything else you would like to add or share with the Social EM community?

I think the movement towards Social EM provides great opportunities. The ED is the intersection between acute care and medical care, and population health is where health care systems are going. Social EM is a way to impact a lot of people, way beyond your individual patients. It is a great career for great emergency medicine physicians.