In the second part of a series of articles, shortages in medicolegal death investigation are placed under the spotlight by Victor W. Weedn, MD, JD, Chief Medical Examiner at Maryland Office of the Chief Medical Examiner
Around the world, medicolegal death investigation offices are understaffed and underfunded despite the critical role they play in government business. The medical examiner and coroner offices struggle to investigate deaths. They are generally chronically under-resourced. Moreover, there is a global shortage of forensic pathologists. Attitudinal and structural hurdles to underfunding and understaffing need to be overcome.
Government structural barriers
Within the U.S. medicolegal death investigation is a state function; the only federal presence is the Armed Forces Medical Examiner system established in 1988. Medical examiner offices are relatively new government entities. As with other new government programmes, they begin as small programmes and grow to meet their demands. Many offices find that they have yet to be fully resourced.
In the U.S., the lack of federal government support for the field is also due to its being orphaned. Other than the military’s medical examiner system, the U.S. federal government does not have a forensic pathology office or program. The number of forensic pathologists among the 80,000 employees of the HHS can be counted on one hand. The Department of Justice (DOJ) sees forensic pathology as a law enforcement concern and public health sees forensic pathology as a law enforcement concern. The Centers for Disease Control and Prevention (CDC) specifically rebuffed an attempt to create an office of forensic medicine within it. Medicolegal death investigation is almost exclusively a state function, and the federal government has little carrot or stick to influence it.
Policymakers often neglect medicolegal death investigation offices that are often buried in the administrative structures. Officials, like most of us, do not want to think about the dead and when they do, they may think that money is squandered on the dead not realising that everything such offices do are for the living.
Medical examiner offices may be adequately funded for less than five U.S. dollars per capita. John Oliver quipped on his show, Last Week Tonight, that offices could be adequately funded for the price of a “Big Gulp” soda.
Forensic pathologist workforce shortage
Even with adequate funding, offices face a worldwide shortage of forensic pathologists. The current opioids crisis and the COVID-19 epidemic have added demand, strained systems to their limits, and exposed the workforce shortage.
In the U.S., there are about 600 board-certified forensic pathologists in active practice — about half of what is thought to be needed. Only about 40 new forensic pathologists graduate from fellowship training programmes per year, which add little as others retire or otherwise leave the field.
One reason for the shortage is the lower salaries of forensic pathologists compared to hospital pathologists. Forensic pathologists require an extra year of training, but then make approximately $100,000 less than hospital pathologists. However, as demand is increasing, wages are being driven up.
The workforce pipeline is dry. In the U.S., there is a shortage of physicians, a greater shortage of pathologists, and an acute shortage of forensic pathologists. Television shows have not translated into significant increases in forensic pathologists. Where education in pathology had been a very significant part of medical school, it is no longer, as curricula now emphasise case-based education spearheaded by clinicians; the built-in pathology component is often lost. This growing lack of exposure to pathology in medical schools has resulted in fewer pathology residents.
Even within pathology residencies, there may be a surprising lack of exposure to forensic pathology. This is so because medical school departments of pathology generally do not perform forensic autopsies and thus have no forensic pathologists on staff. Fellows have complained that some academic pathology faculty have actively discouraged them from going into forensic pathology. If students have not been exposed to forensic pathology, then they don’t know about the opportunities in the field and don’t make it a consideration. In fact, students are attracted to the field in surprisingly high numbers when exposed to the field. The National Association of Medical Examiners (NAME) is working to increase the exposure.
Autopsies are not reimbursed in the U.S. and the number of required autopsies “performed” by pathology residents has decreased and the participation requirement has also been watered down to mere observation. This too detracts from exposure and preparation for a forensic pathology career.
Forensic pathology fellowship is the only medical subspecialty not subsidised by the U.S. Department of Health & Human Services (HHS). This is because the forensic pathology fellowships are in medical examiner offices and not in hospitals and are not considered to be part of the healthcare system. Student loan forgiveness, Visa waivers, and other government medical incentive plans generally also do not apply to forensic pathologists, because they do not treat patients. In fact, it is surprising how many people, including other physicians, do not consider forensic pathologists to be “real” doctors – although they may be the epitome of the doctor who knows everything, but by then it is too late!!
Unrecognised and underappreciated
Every opioids overdose death is diagnosed by a medical examiner or coroner. Despite this key role on the front lines of the crisis, they receive virtually none of the billions of dollars spent on the opioids crisis because they are not seen as fixing the problem. They are not part of prevention, interdiction or treatment. Some funds should be spent on understanding the crisis through the expertise, findings and data of forensic pathology.
Few research funding opportunities
Funding for forensic pathology research is paltry. With rare exceptions, neither the National Institutes of Health (NIH) nor the National Science Foundation (NSF) funds forensic pathology research, because it is seen as an applied science area rather than a basic science area. The little research funding that does exist is from the National Institute of Justice (NIJ), but the total research and development budget of the DOJ is only about 0.01% of the entire federal research and development budget – an insufficient amount to support research in the field. When funding opportunities do arise, forensic pathologists have little time to participate in research activities and offices are not prepared for the administrative burdens of grants. Medical examiner offices are usually outside the academic medical centres and there is little incentive to do research. Most forensic pathology research occurs outside the U.S., judging by the number of articles submitted from outside the U.S. compared to those from inside the U.S. to the major forensic pathology journals.
More should be done!
Governments should adequately fund medicolegal death investigation offices, increased numbers of forensic pathologists should be produced, and mechanisms to increase research conducted in the field should be developed.
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© 2019. This work is licensed under CC-BY-NC-ND.
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Maryland Office of the Chief Medical Examiner
Forensic pathology in Maryland: Hic locus est ubi mors gaudet succurrere vitae – This is the place where death delights to help the living
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