CHAPEL HILL, N.C. — One day in clinic, 2 years ago, a patient handed Adam Goldstein, MD, MPH, a request for a concealed weapon permit, soliciting his signature.
The family physician didn’t know what to do. “What do you mean fill this out on a patient? First off, what do I know about guns and safety? And second, what do I know about that patient?” Goldstein didn’t sign that form, nor has he signed any others that have come into his office since.
Now, prompted by the patient encounter from 2 years ago, the physician says he has embarked on a new research topic: physicians’ role in gun safety.
This hybrid career of clinical practice and research is the right fit for Goldstein, who says he originally set out to work in public health full time, but then found great personal satisfaction in treating patients. “Seeing patients is the great equalizer in academics. If you don’t see patients you don’t get much respect among your peers. The more you do that, the more respect you have. For me it’s always been a dual track,” he said.
Fueled by the concerns of his colleagues facing questions of gun violence, and tragedies like Sandy Hook Elementary School, Goldstein is beginning to publish the first bits of research on family medicine and firearm safety.
Early Career: Forging a Hybrid Path
As an undergraduate at Tufts, Goldstein focused on the sociology of healthcare. He says he found large-scale public health fascinating. But when it came time to choose a career path, he set his sights solely on Augusta State University Medical School, now part ofGeorgia Regents University, with a career goal of working in a public health department.
In medical school, Goldstein took his first steps toward working in public health with preventive medicine community service projects, and by joining Doctors Ought to Care, a physicians’ organization that connects doctors and patients with media literacy tools. But, Goldstein reflects on his clinical rotation, “I realized that I really loved the individual patient care element. Even more so than the public health movement.”
After graduating in 1987, Goldstein decided on a residency at UNC Family Medicine to pursue a career in both academic research and patient care. “I was probably a bit of a pariah” Goldstein says. “Because I wasn’t taking the same path and I didn’t want to go out to a rural practice.” Most of Goldstein’s peers went into rural care.
“I wanted to be in an academic health center: teaching, researching, doing care,” he says.
Tobacco Research Pioneer
That same year, Goldstein published the first study addressing media influence on teen smoking habits. After that initial success, Goldstein says he was under a lot of pressure by his peers in research to forgo practicing family medicine and focus on his funded tobacco investigations.
Instead, Goldstein chose to let go of committee work and other distractions in favor of continuing with both of his passions: patient care and academic research. Goldstein also makes a little time for his creative outlet — poetry, which is mostly about practicing medicine.
After publishing his initial findings, Goldstein expanded this research, and proved that a group of 3-year old kids were just as likely to identify Joe Camel as Mickey Mouse.
“We showed that the more kids recognize tobacco advertising, the more likely they are to become smokers,” Goldstein says. At the time, he remembers, the causal link between advertising and adolescent smoking was controversial.
By 1999, Goldstein had published 15 tobacco research papers. One such paper, published in JAMA, found that 68% of G-rated films produced by five of the big movie production companies in the U.S. included at least one episode of cigarette smoking or other tobacco use.
Jonathan Polansky is a consultant with the UCSF Center for Tobacco Control Research and Education. He says that Goldstein’s early research was among the factors that pressured movie studios into nearly eliminating smoking from modern G- and PG-rated movies.
“Adam played a very important early role in establishing how much smoking was appearing in the movies,” Polansky says. “Over the ages there were bouts of concern about incidents of smoking in the movies with a common sense belief that seeing it caused children to smoke. We now have research that shows a definitive causal relationship between seeing acts of smoking and teenagers’ future smoking behaviors.”
Since Goldstein’s work began, teen smoking has dropped. According to the CDC, in the early 1990s more than 30% of high school students used tobacco. Today, that number is down to 18%.
Goldstein’s work resonates within academia, with 18 of his papers having been cited at least a dozen times by other researchers.
Goldstein brought his mission to change the culture of smoking to his home state, as well. When he first began his research in the 1980s, tobacco farming and smoking were a cornerstone of life in much of the state. Even today, as the industry is beginning to lag, the North Carolina Department of Revenue reports that the Tarheel state still relies on the “bright leaf” for more than 255,000 jobs and $500 million in revenue.
At his own place of work, UNC, in 1998, Goldstein founded a nicotine dependence program to help employees and patients kick the habit and a wellness program that led to the prohibition of smoking on hospital grounds and outside building entrances.
“No one person does anything on their own,” Goldstein says. “But we have changed how people in North Carolina, in the Southeast, and across the country, look at nicotine addiction and tobacco policy. I know that.”
Docs and Guns
On his public health path, Goldstein says his work in tobacco cessation may never be complete. But in the last few years his attention has shifted to what he sees as a new threat to the wellness of his patients: firearm safety.
After being handed the concealed handgun waiver by his patient, Goldstein says he began to wonder about what a doctor’s role in keeping patients and their families safe from gun violence actually is.
The role of doctors in vetting gun safety is an emerging issue in medical societies and courtrooms.
Goldstein says that doctors must be given the tools they need to help guide patients to gun safety before they are tasked with vetting gun owners for licenses.
“I am not a gun researcher,” he says, “Medical boards need to get involved and we need to start developing criteria to help physicians make these types of assessments that have some kind of validity.”
Finding a lack of published research on the topic, Goldstein has been pursuing the issue. Along with several colleagues, he wrote a Perspective for the New England Journal of Medicine questioning physicians’ roles in assessing competency for weapons ownership.
In a preliminary local survey, doctors in North Carolina said they wanted more information and more policy on this topic. Goldstein says he’s engaged an intern to pursue further research and that he’s working on writing more papers and beginning to travel to conferences to speak on this controversial subject.
Taking Over the Airwaves
Several years ago, Goldstein found an intersection between patient care and public health in hosting a radio show. His show, “Your Health Radio,” is a platform for medical research discussions, which he makes accessible to both medical professionals and the general public with his co-host Cristy Page, MD, MPH.
Together, they take calls from the audience and deliver advice on anything from folk remedies to vaccinations.
One day in September of 2014, Goldstein starts to sweat a little before his first-ever live audience.
Dozens of residents and fellows from UNC medical school, eager to hear him interviewMyron Cohen, MD, director of UNC’s Global Health and Infectious Disease department, squeeze into a conference room crammed with microphones, speakers, and a host of recording equipment — thanks to the show’s host station WCHL.
Goldstein questions Cohen about the Ebola epidemic. Attempting to keep the conversation accessible, with a minimum of technical terms, Goldstein says to his guest, “Let me ask you a quick question here. The early symptoms of Ebola — we’re about to be in flu season and it appears to me the symptoms overlap with flu.”
Cohen quickly took advantage of Goldstein’s prompt, explaining the difference between influenza, stomach flu, and Ebola. Guiding his speaker to the explanation was his way of reaching worried listeners in Idaho, rural North Carolina, and further away, for reassurance.
Goldstein spends a half hour after the radio show answering questions from the white-coats in the audience. Later, he reflects on his career and the harmony he has found among supervising students, helping patients, and furthering the course of global health.
“Every physician wonders about whether they are succeeding,” he says. “Every person wonders about trying to do the best they can. I think each and every day is a challenge. The opportunity is there to do well and to do mistakes. I try to improve the ‘do well’ part, and I try to limit my mistakes.”