A Shortage of Medical Examiners Threatens Public Safety and Health
UPATE: The new SB 5523 in Washington state is intended to incentivize scientists to enter the forensic pathologist profession by alleviating the student loan burden.
Read more here.
The U.S. has too few forensic pathologists
The U.S. has only about 400-500 physicians who practice forensic pathology full-time. This is less than half of what has been estimated to meet the current caseload, around 1,100-1,200. The real number needed is probably higher, due to deaths related to the Covid pandemic and the opioid epidemic. Violent crime is often cited as another reason for the increased need but violent crime is actually down.
For example, the Georgia Bureau of Investigation should have 18 medical examiners, but they only have half that currently. Sadly, this is not uncommon in the U.S. For cases which require autopsies, like homicides, fewer medical examiners means deaths take longer to investigate and to close. The recommended caseload for a forensic pathologist is 250 to 325 cases a year. When the caseload gets too high, the quality of the morgue’s work can suffer; the facility could even lose its accreditation. Many forensic pathologists work more than the recommended number of cases out of necessity.
It takes 10 years to become a board-certified forensic pathologist (BCFP)
We’re talking board-certified forensic pathologists at this point, not coroners; that’s a different story to be discussed later. To become a BCFP it takes:
4 years of medical school,
3-4 years of medical specialty training in anatomical pathology or anatomical and clinical pathology, and
2 years in an accredited fellowship year in forensic pathology.
Medical doctors learn how the human body’s systems work and using symptoms to decide why they don’t (health and diagnosis), pathologists learn how to identify specifically what made those systems falter (disease), and forensic pathologists learn about how those systems fail, including violence and trauma (poisons, gunshots, and other bad ends). That’s why forensic pathologists need to spend more time learning and racking up debt. But that’s why…
Medical students don’t want to go into forensic pathology
Nationally, the forensic pathology field is neither well-advertised nor well-paid. Only around 20 graduates a year finish that final fellowship that gets them ready to become board-certified. The average med school graduate shoulders $180,000 in education debt and entry-level forensic pathology positions pay half to one-third that of clinical pathologists. Another way to put the disparity is the average salary for a starting general practitioner doctor is about $220,000 while forensic pathologists start at about $185,000. And GPs have none of the legal duties that medical examiners have, like evidence collection, depositions, and testimony.
Retirements exceed new hires
The number of BCFPs who enter the field each year is not enough to replace those who retire, leave practice, burnout, or die. It’s estimated that the number of pathologists will drop from 18,000 in 2010 to 14,000 by 2030. Retention is also an issue, not just recruitment. With too few applicants and too many openings, the competition for open positions is fierce. Yet, approximately 10% of forensic pathologist positions are vacant because the candidates are not available (like relocation) or the positions are open on the books but there is no money in the jurisdiction’s budget to fill them.
Why this matters: Autopsies are critical to medical quality and the justice system
There are two kinds of autopsies: hospital and medicolegal. A hospital autopsy, sometimes called a post-mortem examination, involves an external and internal examination of the body to determine what disease or diseases caused the patient’s death. A pathologist conducts the process and combines those findings with the patient’s clinical history. Without an autopsy, a doctor won’t really know what their patient died from. Studies have shown that even with advanced medical technology, doctors still misdiagnose the cause of death in up to 25% of patients. The vast majority of deaths in the U.S. are from disease but these are less likely to be autopsied, for a variety of reasons. For deaths due to external causes, nearly all were due to violent deaths (“Assault,” in the graph below; that is, homicide).
Source: https://www.cdc.gov/nchs/data/databriefs/db67.pdf
A medicolegal or forensic autopsy, in contrast, is much more involved. The forensic pathologist (a BCFP) must determine the cause of death (what made the person die) and also the manner of death (natural, accident, suicide, or homicide). Sometimes the decedent must be identified as well as time of death and the documentation of injuries. Evidence will be collected including tissue samples for toxicology. Forensic autopsies are the bedrock of information for deaths that are of interest to the justice system.
Why Backlogs Matter
The Covid pandemic and the opioid epidemic have driven the death rates to unworkable levels for morgues. More than a million people in the U.S. have died in relation to Covid and the rate of drug deaths has tripled since 1999; there were over 70,000 drug-related deaths in 2017 alone. These deaths should have full autopsies conducted, including toxicology and scene investigations, for public safety and health information. Toxicology laboratories are also backlogged, which can add a month or more to finishing an autopsy. Because of the lack of BCFPs, many are not getting the autopsies they deserve. This stunts our knowledge of diseases like Covid, the kinds of drugs involved with drug addiction and usage, and slows down the justice process, letting criminals avoid punishment or clearing the innocent of charges.
What are some possible solutions?
Distribution and consolidation: Regionalizing medical examiner offices or consolidating them to reduce cost and turnaround time (smaller offices handle fewer cases and have shorter reporting times). Partnerships and collaborations with forensic laboratories to expand access to resources has also been suggested. Obstacles include the crazy patchwork quilt of death investigation jurisdictions and how they are administered. This is a topic for future posts.
Money: Recruitment incentives to enter the forensic pathology profession, like loan forgiveness or repayment programs and competitive salary and benefits. A roadblock to this is deciding who pays.
Marketing: Promote the profession to medical students and (forensic) science undergraduate programs; also highlight the adjacent job opportunities, like pathology assistants who help with the autopsy process. Filling the career pipeline is all well and good but the positions need to be available to be filled and paid for.