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Dirty, Smelly, Raw: The Future of Forensic Pathology

— How can we encourage young doctors to join the field?

Last Updated December 12, 2019
MedpageToday

I was just in Kansas City among hundreds of fellow physicians and associated forensic professionals at the annual conference of the National Association of Medical Examiners. In between NAME social events such as the Cadaver Open golf tournament, the Rigor Run morning calisthenics, and the Femme Fatale luncheon, there were phenomenal lectures on cutting-edge forensic medicine and posters on everything from tandem bullets to spurious elevations in ethanol caused by lipemia (which for best resident poster). Despite the great work and exciting research on display at the event, though, my takeaway from the weekend is that the future of forensic pathology is uncertain, and unlikely to be brighter unless we make some major structural changes in death investigation and forensic training in this country.

The number one issue that kept coming up was the critical national shortage of forensic pathologists. This was best illustrated by the outside the exhibit hall advertising job openings. Dr. Milad Webb from the Wayne County (Michigan) Medical Examiner's Office offered some sobering statistics in a presentation on the topic:

The U.S. population is growing at an average of 0.8% (2.6 million people) per year, with an approximately 17% increase in physicians and a concurrent 17% decrease in pathologists.

  • While a 2013 report predicted that the U.S. would require approximately 1,100 board-certified forensic pathologists to cover our nation's autopsy workload, estimates show there are fewer than 500 working full-time today.
  • In 2019, the National Resident Matching Program had an all‐time high of medical school graduates applying for residency match, yet of the 601 pathology residency positions offered, only 569 have been filled.
  • Pathology accounted for only 1.1% of all matched U.S. medical students.
  • Only 41 forensic pathology fellows sat for their board examination in 2019 -- a 16% decline.
  • Only 2/3-3/4 of forensic pathologists practice full time after having completed their forensic fellowship training program.
  • Based on reports from 2012, the average age of an American forensic pathologist was 55, and now it is likely closer to 60.

Worse, the federal government is working hard to worsen the crisis. The current administration took action in September to signal that autopsies are no longer a worthy avenue of medical practice when the cabinet-level Department of Health and Human Services (HHS) released a final regulation to remove autopsy standards for hospitals. HHS justified this change as a means to reduce "regulatory burdens on physicians and the healthcare system." Hospitals are no longer required to have autopsy programs to qualify for Medicare reimbursement. If they find themselves motivated to bury their mistakes, they are now free to do so.

In a letter dated Nov. 19, 2018, the College of Forensic Pathology (CAP) that they strongly oppose elimination of the autopsy standard since "removal of this policy would open the door to not performing or offering autopsies, which will have a significant downstream impact on public health" and "elimination of this policy would further weaken the autopsy, a procedure that historically and currently contributes substantially to both education and patient care." I agree.

At the NAME meeting, there were multiple suggestions on how to address our profession's workflow crisis. Physician assistants could be trained to perform prosection, like they have been trained to "cut in" surgical specimens. Virtual autopsy using CT scanning might be sufficient to offer a cause of death in some cases of traumatic injury. The membership even debated changing the NAME standard requiring an autopsy in some cases of overdose to a standard that would allow for an external examination with toxicology. These solutions address the demand side of the nationwide autopsy deficit by decreasing the thoroughness with which we do our work while allowing for a tolerable error rate. But they don't address the supply side of the equation -- the small and shrinking number of students entering our field. The only suggestion that keeps getting raised for addressing the student supply is loan forgiveness to attract more medical students saddled with debt. That's an inadequate strategy. Forensic pathologists make significantly less money than hospital pathologists do. Why would a debt-burdened young doctor choose a field that requires an extra year of training and offers a lower lifetime income?

Young doctors come into my field in order to do dirty, smelly, emotionally raw manual labor because they are exposed to it at some point during their education and find mentors who are excited and passionate about it. Our field offers a lifetime of fascinating work and intellectual challenge, and a good lifestyle with a generally low burnout rate, though that may change if the staffing shortage persists. As a professional organization we need to advocate for the importance of teaching forensic medicine and pathology to undergraduates, and reach out to academic training programs and to the and the to fix this problem by requiring forensic medicine training in medical school and residency. If you have suggestions on other ways we can encourage students to enter our field, please comment below.

, is a forensic pathologist and CEO of PathologyExpert, Inc. Her New York Times bestselling memoir, co-authored with her husband, writer T.J. Mitchell, is . They've also embarked on a medical-examiner detective novel series with , now available from Hanover Square Press.