More than 650 people were killed by firearms in Oregon in 2022. Oregon emergency departments treated nearly 800 more people with firearm injuries, nearly 70 of whom subsequently died.
Every part of the state is affected by firearm deaths, with suicide by gun more prevalent in rural areas and gun homicides more prevalent in urban areas, according to data from the state’s new federally funded consortium tracking emergency room admissions. Overall, about three out of four deaths were by suicide, according to the Oregon Health Authority’s injury death data.
Against this backdrop, primary care physicians have a responsibility to try and protect their patients from injury and death from firearms, said Dr. Katie Iossi, a physician with the Portland VA and an associate professor at Oregon Health & Science University.
In 2022, Oregon voters narrowly approved Measure 114, that would have required a safety class and a permit to purchase a gun and that would have placed a ban on magazines capable of holding more than 10 rounds of ammunition. The measure has since become embroiled in federal and state lawsuits and was struck down by a judge in Harney County in January. The state has filed an appeal.
Oregon’s overall rate of deaths by gun is 14.9 per 100,000, which is close to the national average. That’s far above the single digit rates in states like Massachusetts, Hawaii and New Jersey that have much tighter gun laws, according to data compiled by KFF Health News.
But new laws are not the only way to make change. Iossi, a member of the Gun Violence Prevention Research Center at OHSU, said that with the right training, respectful language and a spirit of humility, physicians have a real opportunity to keep their patients and their patients’ loved ones safe.
“I think that the most important thing, honestly, is to normalize the conversation around safety when talking about firearms — and normalize that the conversation is not about gun control versus gun rights, but about health and safety,” Iossi told The Lund Report.
The following interview has been edited for length and clarity.
The Lund Report: Could you start by telling me a little bit about your patient population?
Dr. Katie Iossi: I work with veterans at the Portland VA. A large percentage of my patients live more rurally and then travel in to be seen. I mostly care for men, although I have a significant number of women on my panel.
I'd say most of my patients own firearms. Unfortunately, we also know that the veteran population is at a significantly higher risk of suicide.
TLR: What advice would you give primary care doctors about how to bring up guns with their patients?
Iossi: We are trained to ask patients who feel they are at risk of harming themselves how they might do it, what's their plan, what's their intent, and then talking about how we can help keep them safe. Sometimes that comes with explicit training on how to bring up firearms. Most suicide attempts are not done by firearm, but of the of the suicide deaths that are recorded, most are done by firearm.
The most straightforward way is when somebody's at risk for suicide, say: ‘I'm really worried about your health. Thank you so much for sharing with me what you're thinking about. Let’s talk about safety.’
I'd say one of the biggest pieces of advice is not to worry [about] or be afraid of bringing this up because of politics. I think physicians generally know we need to do the right thing by our patient, and really focus on health and safety. And that is around a myriad of public health issues, like vaccines, and you know, wearing seatbelts and using sunscreen and cancer screening and that kind of thing. But it certainly is around firearms too.
Bring it up. Have humility. And recognize that this is a cultural competency. For those of us who are not enmeshed in firearm-owning culture in the U.S., this may be one of the cultures that we will have to be competent in.
TLR: What concerns should primary care doctors have about patients who own guns?
Iossi: We know that over half of deaths by suicide are in patients who don't have a mental health diagnosis and therefore may be being missed in our lethal means counseling that we're trained to do. We also know that more than 60% of people who die by suicide saw a primary care physician in the prior year.
We know that we need to be doing a better job of talking with patients who are at risk of self-harm or harm from others or harm to others. I mean, it's hard to catch everyone. But I think that it's our job to do the best we can to prevent suicide and then also help prevent unintentional injury and other interpersonal injuries as well. When we identify patients at risk, we can recommend secure storage and other interventions to help keep people safe.
Data show that people at risk of injury from firearms include those who use substances, so alcohol is actually a huge risk for intentional and unintentional harm from firearms. [Other risks include]: change in mental status, like dementia, other mental health issues [like] depression, bipolar, things like that.
Intimate partner violence is a huge risk for harm by firearm, especially for women in a home with someone who has a firearm. Also, recent relationship or job loss, history of violence, history of suicide attempts.
And then honestly, just having kids in the home. I take care of a lot of older men, and they don't have kids themselves, but they have grandkids. And a kid as young as three is strong enough to pull the trigger.
I think one of the main things for advice for other doctors is to recognize the risk factors for harm from firearm, which is actually quite a large number of people.
TLR: Do you ask all of your patients whether they own guns?
Iossi: I do.
There's a big debate nationally about ‘Should every physician be screening every patient?’ and ‘Should health systems be screening patients for owning a firearm?’ I certainly think we need to talk about it. And then make recommendations based on the patient's level of risk.
"Bring it up. Have humility. And recognize that this is a cultural competency. For those of us who are not enmeshed in firearm-owning culture in the U.S., this may be one of the cultures that we will have to be competent in,"
TLR: What is the specific question that you ask? “Do you own a gun?”
Iossi: No. I say: ‘Most of my patients own firearms. How do you store your firearms?’
I may know less about firearms than my patients, but I still know what can help save lives and that is storing your firearm securely.
I've had patients who've told me ‘Oh, yeah, I store my firearms like this… In the military, my job was training people in firearm safety.’ And then I learned something. But I also have had patients who didn't think about ‘Oh, well, yeah, I do have my grandson coming into my home. And I should more carefully secure my firearm from unauthorized access.’
[Doctors can also ask], ‘Are there folks in your home who might be at higher risk of suicide themselves and having access to your firearm might give them the opportunity that otherwise they wouldn't have?’ And then the other piece would be ‘[Are there] people in your home who are able to access a firearm and then might harm others?’
Most kids who either do school shootings or other violence or end their own lives, use the gun from their own home. It's like 70% to 80% of people use a firearm they have access to and they’re kids who aren't supposed to have access to firearms.
I would say the first thing is not to be afraid of talking about it, and to expand to the people we recognize who are at risk of harm from firearms.
TLR: Do you offer patients other recommendations for what to do with their guns, beyond safe storage?
Iossi: If we are worried about patients, there are other things we can do.
“Temporary transfer” is something that I recommend to patients. That has actually worked really well for patients who are really worried about themselves and their safety. If they have someone who they would feel safe transferring part of their firearm to or the entire firearm for the period that they're really feeling unsafe, [that can help].
The other piece that a lot of clinicians don't know about is this extreme risk protection order, which is a law passed around 2018 in Oregon. It has been really underused. It's a way that we can try to help keep people safe who are at high risk of hurting themselves or others. Clinicians actually can't file [for them]. But we can recommend it to family, cohabitants and law enforcement if someone should be considered for them.
"We know that over half of deaths by suicide are in patients who don't have a mental health diagnosis and therefore may be being missed in our lethal means counseling that we're trained to do. We also know that more than 60% of people who die by suicide saw a primary care physician in the prior year,"
TLR: Are there federal privacy law concerns with filing a recommendation to law enforcement?
Iossi: That's a great question. Every patient should be aware that in any therapeutic alliance HIPAA is in place unless there's concern about the safety of that person or others. That is pretty standard for all mandatory reporters. If we do have significant concerns that a patient will harm themselves after they leave the office, then I have to do what I think is necessary to keep that patient safe and [keep them] from harming other people.
TLR: How frequently have you had to recommend an extreme protection order?
Iossi: I've never actually recommended it. I mostly think [providers] should be aware of it because I think it's best done by family members in connection with the police, family or cohabitants.
TLR: Do you have any other advice for how doctors should approach these conversations in a non-political way?
Iossi: I guess the last piece is to learn some of the language around how we can be respectful. And to speak to our patients having a dose of humility. This is a harm reduction situation, not a discussion of gun control and of gun rights.
Using words like “secure storage” instead of “gun safety,” or even I sometimes use “safe storage,” but “secure storage” is probably better and more acceptable to some folks. And not [asking]: ‘Are your firearms locked up?’ But: ‘How do you prevent access from unauthorized individuals?’
When I'm talking with the handful of patients who have been worried about their safety [or in] suicidal crisis, say: ‘How about we talk about a temporary or voluntary transfer of your firearm during this time of crisis?’ So, not ‘removing your gun,’ but ‘let's talk about a temporary way of keeping you safe that is voluntary that meets your needs.’
TLR: Is there anything else you want to add?
Iossi: I think that the most important thing, honestly, is to normalize the conversation around safety when talking about firearms and normalize that the conversation is not about gun control versus gun rights, but about health and safety.
I have a couple of patients who, because their PTSD is so so bad from their time in Vietnam, they just can't sleep without personal protection in their bedside stand. As they have other health issues come up, it does make me worried about their safety to have that there. Or if they have grandkids, or whatnot. But it's still a key part of who they are and having that access to that firearm is really important for them for their sense of safety. And so it's really coming to a place that I feel I'm helping them to be as safe as possible and still preserving [their] sense of identity.
For more clinical resources on how to talk to patients about guns, Dr. Iossi recommends the U.C. Davis BulletPoints project.
