EDUCATION

Surgeons and Injury Prevention:What You Don’t Know Can Hurt You!M Margaret Knudson, MD, FACS, Mary J Vassar, RN, MS, Erica M Straus, BA,Jeffrey S Hammond, MD, MPH, FACS, Sylvia D Campbell, MD, FACS

BACKGROUND: The most effective treatment for traumatic injuries is to prevent them from occurring. Cur-rently, few surgeons receive any formal training in injury control and prevention. This study wasdesigned to test the knowledge of injury prevention principles among practicing surgeons, inorder to identify areas in need of intensified educational efforts.

STUDY DESIGN: Survey questions designed by members of the American College of Surgeons Committee onTrauma were programmed into a specialized touch-screen computer, which was displayed atfour different surgery and trauma meetings, including the ACS Clinical Congress in 1999 and2000. Participants were questioned about their knowledge of trauma epidemiology, bicyclehelmet effectiveness, child safety seat usage, suicide, and domestic violence.

RESULTS: Seventy-nine surveys were completed by surgeons, including 33 specializing in trauma care, andby 106 nurses attending trauma courses. Overall, the percentage of correct answers was 50%.There were no significant differences in survey scores between trauma surgeons and generalsurgeons, although both scored higher than trauma nurses. Areas where knowledge deficits werethe most apparent included proper use of child safety seats, the effectiveness of airbags, theprevalence of suicide, and the annual cost of injury in America.

CONCLUSIONS: The majority of practicing surgeons and nurses, including those working at trauma centers, areunaware of the basic concepts of injury prevention. Advancements in the field of injury controlwill require efforts to educate medical professionals and the public. ( J Am Coll Surg 2001;193:119–124. © 2001 by the American College of Surgeons)

Each year, 150,000 Americans die after traumatic inju-ries, and thousands are rendered permanently disabled. 1

Unintentional injuries and violence account for approx-imately 30% of all lost years of productive life before age65, exceeding losses from heart disease, cancer, andstroke combined. Societal costs of injury-related mor-bidity and mortality were estimated at $260 billion inFY 1995. 2 Sadly, the majority of injury deaths occur inthe prehospital setting, before any medical treatment.The only “cure” for these fatal injuries is prevention.Currently, technology exists to prevent or reduce the

severity of most injuries, but many such preventionstrategies are underused and underenforced.

Surgeons caring for trauma patients are in a uniqueposition to offer advice on prevention to the injured andtheir families. Trauma surgeons are also a potential re-source for their community on injury control issues. Butunless the surgeon is knowledgeable in this field, she orhe would be unlikely to provide such education. Thepresent study was undertaken to ascertain the basic levelof knowledge of injury prevention among practicinggeneral surgeons and trauma care professionals. We hy-pothesized that we could identify areas where there was aneed for focused education in prevention strategies forsurgeons.

METHODSThe Subcommittee on Injury Prevention and Control,American College of Surgeons Committee on Trauma,includes in its mission efforts to educate surgeons in thearea of injury control. The members of the subcommit-tee voted to conduct a survey to identify areas where

No competing interests declared.

Sponsored in part by the Centers for Disease Control and Prevention GrantR49-CCR903697-09.

Received January 4, 2001; Revised April 4, 2001; accepted April 18, 2001.From the San Francisco Injury Center, University of California, San Fran-cisco, CA (Knudson, Vassar, Straus) and the Subcommittee on Injury Preven-tion and Control, American College of Surgeons Committee on Trauma(Knudson, Hammond, Campbell).Correspondence address: M Margaret Knudson, MD, Department of Sur-gery, Ward 3A, San Francisco General Hospital, 1001 Potrero Ave, San Fran-cisco, CA 94110.

119© 2001 by the American College of Surgeons ISSN 1072-7515/01/$21.00Published by Elsevier Science Inc. PII S1072-7515(01)01001-8

surgeons had knowledge gaps in their understanding ofinjury prevention. The survey questions were selectedfrom a larger survey that was developed by one of theauthors (JSH) to test surgical residents’ knowledge ofinjury prevention principles.3 Survey questions wereprogrammed into a specially designed iMac Computer(Apple Computers, Inc, Sunnyvale, CA) equipped withtouch-screen technology (ELO Touchsystems, Inc, Fre-mont, CA). The survey was first conducted at the 1999Annual Clinical Congress of the American College ofSurgeons in San Francisco. The computer was located in

the Prevention Booth of the Committee on Trauma inthe convention exhibit hall. Surgeons who visited thebooth were encouraged to complete the survey. Subse-quent surveys were conducted at the annual CaliforniaTrauma Conference (San Diego, CA, 2000), the 2000American College of Surgeons Clinical Congress (Chi-cago), and at a regional meeting of trauma nurses (Trau-ma Education Consortium, 1999, Monterey, CA).

The survey of trauma nurses was included to test thehypothesis that professionals working in trauma centerswould be more likely to be exposed to injury facts in thecourse of their work than those working in other areas ofpatient care. At the end of the survey, the participant hadthe option to submit the test by touching the screen, orto delete the results. Only surveys that were completedand submitted were available for analysis. Answers weredistributed only after the survey was completed.

Statistical methodsOverall mean and median test scores among the differ-ent groups of participants (general surgeons, trauma sur-geons, and nurses) were compared using Student’s t-testwhen data were normally distributed and by the Mann-Whitney test when data were not normally distributed.P values less than 0.05 were considered significant.

RESULTSA total of 185 surveys were analyzed. There were 79surveys completed by surgeons, including 33 specializ-ing in trauma care. Among the 106 nurses who com-pleted the survey, the majority had been practicing forless than 5 years. A total of 134 of the 185 surveys werefrom individuals working at trauma centers. Thirty-ninepercent of those surveyed claimed to have formal pre-vention education programs in their hospital.

Survey questions and their multiple-choice answersare shown in Figures 1–8, with correct answer results forgeneral surgeons, trauma surgeons, and nurses presentedseparately. As can be seen, the majority of the surgeons,but only 31% of the nurses, correctly identified motorvehicular trauma as the most common cause of fataloccupational injuries (Fig. 1). Most of the physiciansand nurses correctly noted that bicycle helmets decreasethe risk of head injury by 85% (Fig. 2). Surprisingly,only 37% of surgeons and 50% of nurses knew that thesafest place for a child in the car is the rear middle seat(Fig. 3). The overwhelming majority of those surveyedoverestimated the effects of airbags on reducing mortal-

Figure 1. Answers to the question regarding the most commoncause of fatal occupational injury.2 The asterisk marks the correctanswer.

Figure 2. Answers to the question about the percentage of de-crease in head injury rates resulting from the use of a bicyclehelmet.20 The asterisk marks the correct answer.

120 Knudson et al Surgeons and Injury Prevention J Am Coll Surg

ity, as shown in Figure 4 (correct answer is 15%). Figure5 demonstrates that only 46% of the medical profession-als surveyed knew that suicide deaths outnumber homi-cide deaths. In contrast, almost everyone has learnedthat injury is the leading cause of death up to age 40 (Fig.6). As might be expected, trauma surgeons who weresurveyed were more familiar with the estimated cost ofcaring for injuries in the United States (Fig. 7). Finally,most nurses and doctors were aware that severe injuriesrarely occur early in the domestic abuse cycle, but dooccur if the cycle of violence is not interrupted (Fig. 8).

When comparing the overall percentage of correctanswers provided by the three groups, the trauma sur-geons scored significantly higher than the nurses (p 50.018). Trauma surgeons also scored higher than thegeneral surgeons, but not significantly (p 5 0.071). At

the end of the survey, 72% of the surgeons and 71% ofthe nurses strongly agreed that formal education in in-jury prevention should be included in surgical and nurs-ing education programs.

DISCUSSIONInjury is the leading cause of death in America for per-sons aged 40 years and younger. In 1995, 59 millioninjury episodes occurred and resulted in hospitalizationfor 2.6 million patients.2 There were 37 million personstreated in emergency departments for injuries during

Figure 3. Answers to the question about the safest place for a childto ride in a car.21 The asterisk marks the correct answer.

Figure 4. Answers to the question on the mortality reduction attrib-uted to airbags.21 The asterisk marks the correct answer.

Figure 5. Answers to the question: do suicides outnumber homi-cides?22 The asterisk marks the correct answer.

Figure 6. Answers to the question: is injury the leading cause ofdeath up to age 40?1 The asterisk marks the correct answer.

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that year and 147,891 injured patients died. Of all ofthese deaths, 77% involved adolescents and youngadults (aged 15 to 24 years). Injury and its consequencesaccounted for 12% of all medical dollars spent, with thecost of injury estimated at $260 billion in 1995.1 Thisnumber is significantly higher than the $180 billion pre-viously publicized (the correct answer for our survey),

and includes both direct costs for hospitals, drugs, andphysician services, and indirect costs for lost wages.1,4 So,injury remains the most costly public health problem inAmerica. Ironically, in the year 2000, technology existsthat can significantly reduce the mortality and morbid-ity related to injuries. Clearly, there is a disparity be-tween strategies demonstrated to prevent or reduce in-juries and the application of these strategies. This surveysuggests that surgeons and other medical professionals,through their lack of knowledge, could be contributingto this disparity.

Injury control involves an integrated effort that in-cludes education, enforcement, and engineering. Physi-cians are most likely to make significant contributions inthe area of education, but this requires that they them-selves have received the necessary training. An exampleof a program aimed at training medical personnel ininjury control is found in the area of domestic violence.An estimated 25% of women in the emergency roomsetting are victims of intimate partner abuse, and ap-proximately $67 billion is spent annually on victim-related costs of domestic violence.5,6 Because severe in-juries occur late in the domestic abuse cycle, there is anopportunity to intervene before serious physical trauma.McLeer and Anwar 7 reported that instituting a protocoldesigned to train medical personnel to identify batteredfemale patients in the emergency setting resulted in anincreased recognition of abused women from 5% to30%.7

In another study, pediatric residents who had receivedintensive training in the use and installation of childsafety seats were found to be more likely to discuss theiruse with parents when compared with residents who hadnot received this training.8 In fact, pediatric residencyprograms have been among the first to incorporate pre-vention programs into their training programs. A recentsurvey of pediatric residency program directors revealedthat 80% to 90% of programs include comprehensivetraining in disease prevention (heart disease, lead poi-soning, cancer, etc.), but only 50% to 60% addressedinjury prevention topics in a comprehensive manner.8,9

A recent review of the literature performed by membersof the American Academy of Pediatrics cited 20 high-quality articles demonstrating the effectiveness of pri-mary care-based counseling to prevent childhood unin-tentional injuries.10 In 15 of these studies, pediatriciansperformed the counseling themselves.

Martinez,11 former director of the National Highway

Figure 7. Answers to the question asking for an estimated cost ofinjury in the US.4 The asterisk marks the correct answer.

Figure 8. Answer provided regarding identifying the incorrect state-ment about domestic violence from the following potential answers:10–12 A. 22% to 35% of emergency room visits are for symptomssecondary to abuse; B. 64% of hospitalized psychiatric patientshave a history of abuse; C. Pregnancy increases the risk of abuse by50%; D. Severe injuries occur early in the domestic violence cycle.The asterisk marks the correct answer.

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Traffic Safety Administration, outlined the role of theemergency physician in injury prevention. He empha-sized that injury control should be a natural concept forthe emergency physician to grasp and to develop withinthe community. More recently, a survey was mailed to461 residents of the 13 emergency medicine residencyprograms in California.12 There were 97% of respon-dents who said they believed injury prevention was per-tinent to emergency medicine, but only 44% had re-ceived lectures on this topic. The majority of theseresidents believed they were inadequately trained in thefield of injury prevention.

As stated by Mucha,13 trauma “prophylaxis” is theresponsibility of every physician, but particularly thosewho are armed with both anecdotal experiences in thecase of trauma victims and factual, epidemiologic da-ta.13 Several recent reports would suggest that manysurgeons are now incorporating injury and violenceprevention into their professional activities.14-16 Sim-ilarly, leaders in the American Association for the Sur-gery of Trauma, the Eastern Association for the Sur-gery of Trauma, and the American College ofSurgeons have strongly endorsed the role of surgeonsin the field of injury and violence control. Based onour study, we must conclude that the majority of sur-geons are still poorly educated in injury control andprevention. As reported by Cassel and associates,14

although 84% of internists and 72% of surgeons be-lieve that physicians should be involved with injuryprevention in the area of firearms, less than 20% ac-tually incorporate prevention practice in patient care.

We acknowledge that our study is small, and thatthere is an element of selection bias (ie, only those sur-geons and nurses who chose to complete the survey wereincluded). But, if anything, this bias would skew ourresults to a more knowledgeable cohort who chose tovisit the prevention booth or to attend trauma confer-ences. So it is likely that a larger random sample woulddo worse on the survey. This would indicate that indeed,we have a lot of educating to do. Additionally, the ques-tions were limited in scope and there was no attempt tocover all areas of injury prevention because we wanted tokeep the survey brief. But, we intend to continue ourwork, and our expanded survey will include a short ed-ucational component along with each question. Incor-poration of this survey and directed answers on our in-teractive web page will allow us to gather data across

various medical disciplines while providing an easily ac-cessible educational venue.

We believe that injury prevention education shouldbegin in medical school and be common to all disci-plines. For example, because most young women usetheir gynecologist/obstetrician as their primary healthcare provider, what better place to educate these womenon the importance of proper use of restraint devices,both during and after pregnancy? Pediatricians need tobe well versed in effective prevention measures and de-vote time during routine visits to educating parents.Currently, less than 50% of accredited US medicalschools include injury prevention in their required cur-ricula and only 30% offer nonclinical elective opportu-nities in this area.17 Additionally, despite the incorpora-tion of preventive medicine into the curricula of morethan three-quarters of medical schools, cardiovasculardisease prevention and cancer screening guidelines re-ceive more emphasis than injury control.18

The Prevention Subcommittee of the American Col-lege of Surgeons Committee on Trauma has just begunthe work of designing a comprehensive injury controleducational program for medical students. Dr. DavidHoyt, chairman of the Committee on Trauma, has ad-dressed the need for such a program in a letter sent to allmedical schools accredited by the Association of Amer-ican Medical Colleges. We hope that the readers of ourreport will be inspired to support these efforts, whichhave the potential to significantly advance the field ofinjury prevention and control. Additionally, every sur-geon has the responsibility to become involved in thefield of injury control in some fashion. Regionally, thesurgeon can be a powerful advocate for grass-roots pre-vention efforts and a strong voice in the local media.Although a review of all areas of injury prevention andcontrol is beyond the scope of this manuscript, an ex-panded list of resources (both locally and nationally) iscontained on the web pages of the Centers for DiseaseControl National Center for Injury Prevention andControl (www.cdc.gov/ncipc), the American Associa-tion of the Surgery of Trauma (www.aast.org), the East-ern Association for the Surgery of Trauma (www.east.org), and the American College of Surgeons, Committeeon Trauma Prevention pages (www.facs.org). Finally, sur-geons are encouraged to participate in prospective trialsthat evaluate the outcomes of injury control strategies aswe attempt to translate effective interventions intopractice.19

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