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With funding from the Stepping Strong Center, innovators at MGH are using an immersive platform to develop a broadly scalable, virtual reality-based gun violence prevention curriculum for healthcare workers. The image above simulates a pediatric clinic setting with a parent and child patient avatar.

Innovator Award recipient Cornelia Griggs, MD, is a pediatric surgeon at Massachusetts General Hospital, the director of education at the MGH Center for Gun Violence Prevention, and a passionate advocate for preventing gun violence. Donna Woonteiler and Cheryl Lang met with Dr. Griggs to discuss her Stepping Strong-funded project—an avatar/virtual reality-based gun violence prevention training program for clinicians—and the importance of using a public health approach to unravel the challenge of gun violence in the U.S.

Q:  Welcome, Dr. Griggs. Let’s start by talking about how you came to be interested in gun violence prevention.

CG: For many years—first in my role as a trainee in adult general surgery and trauma, and then as a pediatric surgeon—[my co-PI in the Stepping Strong project] Peter Masiakos and I have had a passion for using medical and human narratives as a way to advocate for gun violence prevention. Well before the NRA sent out that nasty “stay in your lane” tweet in 2018, Peter and I worked on developing a proposal for a university-wide gun violence prevention center and had written about our experiences treating victims of gun violence in an article called “The Quiet Room” in The New England Journal of Medicine.

Q: We’ll get back to that tweet. But first, tell us about the data. How many Americans die at the hands of gun violence every year?

CG: More than 45,000 Americans died in 2021. It was the deadliest year in America ever. We now know that gun violence is the No. 1 cause of death for children in the United States, surpassing motor vehicle crashes. That statistic alone I find to be particularly gruesome, unacceptable, and singularly American. There is no other country that even comes close. And that is one of the reasons why as a pediatric surgeon I feel so activated about this work.

“Gun violence is the No. 1 cause of death for children in the United States, surpassing motor vehicle crashes… And that is one of the reasons why as a pediatric surgeon I feel so activated about this work.”

Q: Given these alarming statistics, one has to wonder if the sound of gunshots has become normalized in some communities.

CG: Yes. We have children growing up who have become accustomed to the sound of gunshots when they’re outside just trying to enjoy a birthday party. As a mother, I hate that containment drills have become a part of everyday American public-school education. As a trauma surgeon, I do what I can to fix bullet-related injuries. But just healing the wounds is not enough.

Q: In 2018, the NRA’s “stay in your lane” tweet you mentioned earlier galvanized a movement among healthcare workers. Can you explain its impact?

CG: In response to that nasty tweet, many colleagues have contributed editorials in lay publications and medical journals and taken a vocal stance on social media. My friend Joe Sakran–a trauma surgeon at Hopkins and a survivor of gun violence himself–initiated the hashtag “this is our lane,” which led to a coalition among thousands of healthcare workers, including Peter and me, who want to help people understand what it’s like receiving a child who has been shot in the trauma bay.

In some ways, the NRA tweet was one of those reverse causation events in which something that was meant to be a nasty aside actually created momentum. We recognized that in order to move the dial on gun violence in our country, we had to activate a generation of healthcare workers to embrace a public health approach to protect families and children against gun violence.

Q: Going back to your statement that “just healing the wounds is not enough,” what would be enough?

CG: We are only beginning to understand how gun violence affects a person’s health and long-term outcomes. Take the recent school shootings in Uvalde, Texas, and consider the impact, stress, and distress the event caused internationally.
That said, we’ve made some progress. The first meaningful gun violence prevention legislation was recently passed in the last 30 years. Today there’s a real opportunity to use science, harness the tools of public health, and dismantle policies that have made people think there’s nothing we can do for so many decades. I refuse to adopt that narrative.

Q: Talking about using science, you and Peter Masiakos received a 2021 Stepping Strong Innovator Award for your project, Developing and evaluating an avatar/virtual reality-based gun violence prevention training program for clinicians. Tell us about the origins of that work and what you’re trying to accomplish with the new curriculum.

CG: Unfolding from the movement in 2018 and even earlier, there were a lot of passionate physicians interested in empowering other healthcare workers to play a more active role in screening for patients at risk of gun violence and using the healthcare setting as a touch point to begin conversations. At MGH, we started from a place of just saying yes; this is something we should be teaching our trainees. This is something we need to bake into the culture of healthcare.

Our solution was to develop a novel curriculum that addressed the tenets of adult education with an understanding that people, especially around sensitive issues, learn best in a simulation environment, where they have the opportunity to ask questions in a safe learning space. We use standardized patient actors to simulate real-time patient interaction.

Q: Who did you train?

CG: OB-GYN residents, medicine residents, surgery residents, psychiatry residents, and pediatrics residents. To date, we have put more than 400 residents through gun violence prevention training.

Q: What are some of the things they learn?

CG: They learn how to talk to patients about “red flags” or ERPO (Extreme Risk Protection Order) laws, how to speak about safeguard storage, and how to help patients identify situations in their own homes, families, and communities that could put them or their loved ones at risk. We also provide language to take that conversation outside of the healthcare setting. We had a great response to those initial trainings and residents were hungry for more.

Q: Were you able to measure their performance?

CG: We have a survey-based tool that everyone takes after the training in which people rate their confidence and their understanding. We also studied residents before and after the training, and our results showed a huge leap in confidence in terms of talking to patients about gun violence prevention in their own clinics, in the emergency room, and in settings where we felt healthcare workers would have a really valuable opportunity to intervene and help break the cycle. The ripple effect of just having the conversation is something that is difficult to measure but something we really believe in.

Q: It sounds like you had great success with the initial program. Why are you moving to an avatar-based curriculum?

CG: After we started deploying the curriculum, a lot of hospital systems came to us saying, “We want to do what you’re doing at our hospital.” But training the standardized patient actors is a resource- and time-intensive undertaking. When it started, it was in-person. And then in the pandemic, we moved a lot of it to Zoom. So we started to think about how we scale this; how we make the curriculum cheaper, faster, more efficient, and accessible to the masses.

That’s when we started talking to the Media Lab at Cincinnati Children’s Hospital. Our partners there have been so valuable because they had already developed this avatar-based platform for healthcare workers to talk to their patients about vaccines. Since they had this sophisticated technology built and ready to go, we decided we could build our gun violence prevention curriculum into this avatar-based platform, with the thought that we want our curriculum to be able to scale nationally.

Q: Such a great example of multi-disciplinary, multi-institutional collaboration! How close is it to implementation?

CG: We’re getting very close to being able to test the platform and expect the first training to take place in the early fall at MGH and the Brigham. For the initial pilot, we’re going to start with 25 residents and then after the beta pilot probably go up to 50 and then hopefully expand rapidly from there.

Q: Are there concerns with taking away the human component? How does it work for somebody to have a conversation with a human versus an avatar?

CG: You do potentially lose some of the subtleties of human emotion or facial expressions or body language with an avatar. But our pilot studies will give us the opportunity to improve and iterate and tweak things and also to understand if the outcomes are equivalent. We want to understand Do residents feel just as confident coming out of the avatar-based curriculum as they do from the standardized patient curriculum?

I also want to respect that this is a new generation that we’re training, where a lot of them have lived their lives online interacting in these virtual environments. We are dipping our toes into really novel, modern, innovative territory. And that’s why having grants like this is really exciting–it allows us to take what we’re already doing, what we already know works well, and test it in a totally different, highly technologically savvy platform.

“With the avatar-based curriculum] we are dipping our toes into a novel, modern, innovative territory. Having grants like this is really exciting because it allows us to take what we’re already doing … and test it in a totally different, highly technologically savvy platform.”

Q: It’s fascinating work, and we are very grateful you took the time to speak with us today. Any last thoughts? What excites you most about the program?

CG: I first want to say how deeply grateful we are to the Stepping Strong Center for believing in our work and being amazing champions of this topic.

As far as what excites me, it is the potential for community members to engage in a critical conversation. A family member, friend, or patient can step up and say, “I’m scared about my son.” Or “My uncle’s behavior has been really erratic lately, and I know for a fact he has access to firearms.” We want to create that space in the healthcare setting for people to divulge, to ask questions. And then on the other end for healthcare workers, having gone through our curriculum, to have the language, and tools, to understand the laws, to know the next best phone call to make, or the next best place to guide that patient. Those are huge opportunities.

Dr. Griggs and her co-PI Peter Masakios, MS, MD, are part of a multi-sector group of Boston leaders who seek to interrupt cycles of violence. Based at Emerson College, the Transforming Narratives of Gun Violence Initiative seeks to create story-based solutions through arts, media, and communications. Learn more.

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