By Jennifer Ferris
MedPage Today/ North Carolina Health News
One day in clinic, two years ago, a patient handed Adam Goldstein 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 the others that have since come into his office at UNC’s Family Medicine Clinic in Chapel Hill.
At the time, Goldstein didn’t know anything about gun safety issues, but he’s no stranger to public health. For nearly 20 years, he’s been the guy showing the world how tobacco use in the media turns kids onto smoking and dipping. This research has changed U.S. policy. And teen smoking rates have dropped by nearly half since he began.
Now, prompted by that patient encounter from two years ago, Goldstein said he has embarked on a new research topic: physicians’ role in gun safety.
This hybrid career is the right fit for Goldstein, who said he originally set out to work in public health full time but found great personal satisfaction in treating patients.
Early career: Forging a hybrid path
As an undergraduate at Tufts University, Goldstein focused on the sociology of health care. He was fascinated by large-scale public health. But when it came time to choose a career path, he set his sights solely on Augusta State University Medical School, now part of Georgia 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. But, said Goldstein, “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.
Most of Goldstein’s peers headed into rural care. “I wanted to be in an academic health center: teaching, researching, doing care,” he said. “I was probably a bit of a pariah, because I wasn’t taking the same path and I didn’t want to go out to a rural practice.”
Chapel Hill writer Simone Soltan was among Goldstein’s first patients when he moved to Chapel Hill in 1993. She met him at the Judea Reform Temple in Durham when he approached her with the idea of building a Jewish Day School, an amenity missing from his new hometown. The two worked together to found the school and to run a capital campaign for a new building.
“He was so involved in this, even though his eldest son wasn’t even old enough to attend yet,” Soltan said.
Goldstein’s wife, also a physician, took a position at UNC. The couple had three children and built the school with Soltan as a place where their kids could learn Hebrew alongside math, science and reading. The school is now in its 19th year and is among the more highly rated academic offerings in the Durham area.
Although not as active in the school since his children moved on – they’re now all in college or have graduated – Goldstein still volunteers extensively, both locally and abroad. After the 2010 earthquake, he traveled to Haiti, delivering frontline medical care to those in need. On the plane back from that disaster zone, he penned poems about what he witnessed. He found the meditative scratching of pen on airsick bag helpful to processing his helpless feelings in the face of devastation.
Tobacco research pioneer
During his first year at UNC, Goldstein published his first study addressing media influence on teen smoking habits. After that initial success, Goldstein said he was under a lot of pressure by his peers in research to forgo practicing family medicine and focus on tobacco investigations.
Instead, he chose to let go of committee work and other distractions in favor of continuing with both of his passions: patient care and academic research.
After publishing his initial tobacco 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,” he said. 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 paper, published in JAMA, found 68 percent 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, a consultant with the UCSF Center for Tobacco Controlled Research and Education, said that Goldstein’s early research was among the factors that pressured movie studios into nearly eliminating smoking from G- and PG-rated movies.
According to the CDC, in the early 1990s more than 30 percent of high school students used tobacco. Today, that number is down to 18 percent.
Goldstein set out to change the culture of smoking in North Carolina too. At UNC, he founded, in 1988, 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 said. “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 said 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.
Fueled by the concerns of his colleagues facing questions of gun violence, and tragedies like the shootings at Sandy Hook Elementary School, Goldstein is beginning to publish the first bits of research on family medicine and firearm safety.
After being handed that first concealed handgun waiver, he said 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.
In April 2014, the American College of Physicians began to publish on the topic. A 2014 Florida Court of Appeals ruling upheld a law that limits doctors’ ability to discuss gun safety with patients. The American Academy of Pediatrics called the decision a violation of First Amendment rights and is appealing the ruling.
Goldstein said 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 said, “Medical boards need to get involved and we need to start developing criteria to help physicians make these types of assessments that has some kind of validity.”
Along with several colleagues, Goldstein authored a prospective paper published in the New England Journal of Medicine questioning the physician’s role in assessing competency for weapons ownership.
In a preliminary local survey, doctors in North Carolina said they wanted more information and policy on this topic. Goldstein said he’s engaged an intern to pursue further research and he’s working on writing more papers. He’s also beginning to travel to conferences to speak on the subject of doctors’ roles in gun ownership.
Taking over the airwaves
Several years ago, Goldstein found an intersection between patient care and public health through 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 cohost Cristy Page.
Together, they take calls from the audience and deliver advice on anything from folk remedies to vaccinations.
One day in September, Goldstein started to sweat a little before his first-ever live audience.
Dozens of residents and fellows from the UNC medical school, eager to hear him interview Myron Cohen, director of UNC’s Institute for Global Health & Infectious Diseases, squeezed into a conference room crammed with microphones, speakers and a host of recording equipment – thanks to Chapel Hill’s host station, WCHL.
Goldstein questioned Cohen about the Ebola epidemic. Attempting to keep the conversation accessible, with a minimum of technical terms, Goldstein said to his guest, “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 rural North Carolina, Idaho and beyond for reassurance.
Goldstein spent a half hour after the radio show answering questions from the white-coats in the audience. Later, he reflected 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 said. “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.”[box style=”4″]
This story is part of a partnership between MedPage Today and North Carolina Health News. The collaboration will make it possible for us to publish regular profiles of health care professionals from North Carolina.[/box]