What a Shortage of Forensic Pathologists Means for Public Health

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: what happens when we don't have enough people working as forensic pathologists; and an urgent call to action before public health pays the price.

DR. TRACIE COLLINS:
Forensic pathology is a very important field, you know. We need them to understand the causes of unnatural deaths, and really assess what's happened, and to provide that information to the public so that we can make changes and impact health positively for those who are living.

DR. KURT NOLTE:
Forensic pathologists investigate deaths to serve the living and, therefore, it is important for everybody in our community that we have viable, skilled, comprehensive medical-legal death investigative offices to be able to protect the health of everybody.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, we examine the urgent need to find hundreds of new recruits to work as forensic pathologists, a field with not enough people to handle a growing number of cases—the information from each vital to public health.

Our guests on this episode say the stakes are high and they're asking their colleagues across the states and territories to consider reforms they believe could help bring reinforcement to a critical yet often neglected profession with a huge impact on public health.

Dr. Kurt Nolte is a professor of pathology and radiology at the University of New Mexico. He also is the former chief medical investigator for the state of New Mexico. He's along shortly with a list of actions he thinks could help alleviate the workforce problem.

But first, we visit with Dr. Tracie Collins, secretary of the New Mexico department of health, about the need to bring more people into forensic pathology as soon as possible.

COLLINS:
Forensic pathology is a very important field, you know. We need them to understand the causes of unnatural deaths, and really assess what's happened, and to provide that information to the public so that we can make changes and impact health positively for those who are living.

What's going on with forensic pathology is that there's a lot of training that's involved in that—you go to medical school or a DO school, and then you go through a residency, you have to go through training—and the pay is really not comparable to a lot of other medical specialties. It's pretty low.

So, you've got a lot of time that you're committing, potentially loans that you're taking out; and then, at the end of it, you don't get much of a salary to help pay off those loans. So, it's challenging to identify people to commit to that, given those challenges.

JOHNSON:
So, given the situation that we find ourselves in now, is it a case of not having enough people to fill currently vacant positions? Or is there just too much work, which means we need more people to do it?

COLLINS:
You know, it's both.

We have about 500+ forensic pathologists in the country and we need about 1000. And so, when you think about that was where we started from, and then a pandemic hits, and you have these deaths and really a backlog—it's challenging because we don't have enough people and we have now more work to do.

JOHNSON:
We're worried about a lot of problems getting worse because of the pandemic—drug overdoses, suicides, mental health issues, just so many different things going on—and, from what we know, forensic pathology touches a lot of those issues in different ways.

How would you characterize, given all of that, the importance of solving this crisis of recruitment as soon as possible?

COLLINS:
With the issues around substance use disorders and deaths related to that, we are in a position where we have to identify more candidates, we have to identify more forensic pathologists, get them trained appropriately, and get them out into the various communities.

And so, it is urgent that we identify a way to increase the pipeline, to increase retention, and to identify really good people.

JOHNSON:
But, as you said, it takes a while to train someone. If I raised my hand today day, I would not be working in this field in six months.

COLLINS:
Oh, absolutely not.

You know, you have the four years of medical school or DO school—osteopathy—and then you've got at least some more training in anatomy and other areas, and then you have at least a year of residency or fellowship in forensic pathology.

So, we're talking at least six, seven years before you're ready to practice if you started today.

JOHNSON:
I'm sure you've heard of the Fauci effect, this idea that people are signing up now to go into public health careers because of the pandemic.

Do you think forensic pathology will benefit from this renewed interest in this kind of work?

COLLINS:
There's potential for it to benefit. I think Fauci is amazing, and we've been fortunate to have him as one of our leaders to get us through this pandemic; but it's going to take more than an interest in public health to increase the number of forensic pathologists. We need forensic pathologists helping to recruit and helping people understand the value of this profession.

And, on the policy side, we've got to do better about: increasing the wages; what we're doing with training—is there any way to streamline it and still get quality people; and then, really increase those numbers of potential forensic pathologists; and get people engaged as soon as they are interested—especially in med school or DO school—so that we have them ready to go.

And so, I think the interest now in public health is a start, but we've got more work to do.

JOHNSON:
Our audience is made up of leaders like yourself.

What's their plan? What can they do? How can they help get this process moving?

COLLINS:
We need to do two things—or a few things, I should say.

We need to begin to put forensic pathologists in the forefront so people see them, know their value, and we're not just talking about them during this historic event of a pandemic.

And then, we need to evaluate what are the wages, how do we increase their wages, how do we retain people in this profession?

And then, make sure that we're providing good support. I mean, a lot of these OMI offices—medical investigators—around the country have been really flooded because of the pandemic. So, they need our support, and I think if the community sees that, there'll be more interest as well in forensic pathology.

JOHNSON:
So, you think more people would sign up for these careers if they knew the connection between forensic pathology and the health of their communities.

COLLINS:
Absolutely.

JOHNSON:
What can you say to a young person who's interested in public health and is looking at that because of everything that's happened, but might not be thinking specifically about this line of work?

COLLINS:
For someone who's thinking about public health, that it is really a rewarding field from the vantage point of making a difference.

So, sometimes when you think about forensic pathology, you think, well, these are dead people; but what we're learning about their deaths can help the living. So, you can make an impact in public health by going into forensic pathology.

JOHNSON:
Can you give us an example of how that connects—you've summarized it for us, but let's get into the detail a little bit more—like how does an autopsy finding make me healthier?

COLLINS:
So, if we know that there's an infectious disease that's out there—that's killing people—and we've had that experience, then, from that information, we could take it back to the public and go upstream and begin to make changes to prevent others from succumbing to that infection.

JOHNSON:
That information is not just kept within the jurisdiction where that work's going on. It's shared nationally, and people can start to identify whether trends are emerging—that sort of thing?

COLLINS:
Absolutely.

JOHNSON:
Looking ahead, then—given that we need twice the number of pathologists on the job today—what happens if we don't get more people interested in this career?

COLLINS:
We're going to have more challenges with getting things done efficiently. We're not going to be able to complete those autopsies as efficiently as we should. We're looking at challenges with trying to keep bodies in cold storage for an extended period of time.

So, it's really a problem if we can't identify more forensic pathologists.

JOHNSON:
Do you think that more people like yourself are starting to pay attention to this issue, or do we have some work to do there as well?

COLLINS:
I think more people are paying attention, but you can always do more.

JOHNSON:
Dr. Kurt Nolte is a forensic pathologist worried about his colleagues' ability to keep up with a growing number of cases—deceased people whose deaths might hold clues that can protect the health of the living.

Today, he teaches pathology and radiology at the University of New Mexico. For nearly five years, he was the state's chief medical investigator.

His mission now—to get public health policy policymakers focused on the problem of not enough forensic pathologists to get the work done.

NOLTE:
The delta between what we have and what we need is about 800 forensic pathologists. And the pipeline is complex. There are about 30,000 medical students who graduate each year—only about 600 of them go into pathology.

And there's actually a bottleneck for residency because the residency positions are funded by Medicare, and there are now more medical students than there are resident positions. Medical schools have been increasing the number of physicians, but we don't have an adequate number of residency slots. So, we're bleeding off trained physicians who can enter residency.

So, about 600 enter into pathology residencies; and, of those, about 7%—or 40 a year on average over the past decade—go into forensic pathology. And so, that pipeline is important, but it's hard to overcome that pipeline to reach the number of forensic pathologists that we have needed for a long time.

For example, if we double the number of forensic pathologists coming through that pipeline—which would be truly extraordinary—it would take us 20 years to make up those 800 forensic pathologists, and that doesn't even account for the pathologists who die or retire in that interval of 20 years.

The pipeline is made more challenging by outside forces. For example, we're looking at a national physician shortage. The American Association of Medical Colleges has predicted we're looking at a 54,000–139,000 doctor shortage in the next 12 years.

And that's made more complicated by the demand for primary care physicians, for geriatricians, for addiction medicine specialists, for mental health specialists—consider the sorts of problems our society is facing and the aging of our population. So, the AAMC is very concerned about that. At the same time, the College of American Pathologists is projecting a shortfall of pathologists of about 22% in the next 10 years.

So, the pipeline is important for us to at least be able to hold our position and likely make small gains, but solving the forensic pathology shortage is not going to happen entirely through the pipeline. The math just doesn't work out.

JOHNSON:
So, what are some of the solutions that local jurisdictions might pursue?

NOLTE:
There are several approaches.

One would be the approaches that could come out of states—out of state and territorial health leaders, at a public safety and criminal justice office, and from policymakers.

For example, less than 10% of forensic pathologists work in academic health centers. But where are the learners? Where are the medical students and where are the residents who will become forensic pathologists?

They are in academic health centers, and states could really foster the recruitment of medical students and pathology residents if they base their medical-legal death investigative agencies in academic medicine, and that is not uncommon in other countries—for example, in Europe, that's where they're typically based. But in the U.S., they are not. Most medical schools, 90% of the medical schools, do not have full time forensic pathologists on their faculty. So, the ability to influence is one thing.

The sorts of work environments that states and counties provide forensic pathologists—most medical examiner agencies are aging and lack technology. So, for example, biosafety. Biosafety is critically important when you're performing autopsy—COVID is an example of that, but all of the bloodborne pathogens, airborne pathogens, such tuberculosis—we still have forensic pathologist performing autopsies in funeral homes.

How does that look to trainees who are thinking about a discipline when they go into a bright spanking technology-adorned operating room with a surgeon, and then they follow a forensic pathologist who does his procedure in a funeral home? So, work environment is really important.

Computerized databases: only one-third of medical-legal death investigative agencies in the U.S. have computerized network databases. One-third do it completely on paper, and one-third have some mix.

So, imaging technology can be very, very helpful for pathologists and it could make the field more attractive to individuals who are getting used to using technology while they're in medical school and in their residency programs.

Ancillary staff: states and counties can provide helpful ancillary staff to the forensic pathologists. For example: forensic photographers, forensic anthropologists, forensic odontologists; and providing those staff can actually help decrease that work load that forensic pathologists face.

Regionalization: so many of our offices are on a county base with a very small scale in their population. They might have one or two forensic pathologists; or, if they're coroner-based, they might have no forensic pathologist and contract out to somebody else.

But regionalization provides an economy of scale. It brings groups of forensic pathologists together so junior forensic pathologists don't feel like they're practicing in isolation—they have colleagues. The economies of scale also make it more affordable to have the information technology and office needs, the imaging technology and office needs and other technologies. So, states should look at regionalization if they want to make their states more attractive to forensic pathologists.

And, certainly, there are always salaries, and trying to get salaries that are competitive with what medical trainees would make entering other disciplines could help bend people who have an inclination to forensic pathology but are wary about a discipline that's going to make it difficult for them to repay their loans.

And then, states have a number of intrinsic partners in the public health community who could work with forensic pathologists. For example, the individuals who work in the National Violent Death Reporting System, the Sudden Death in the Young program, the State Unintentional Drug Overdose Reporting System; all of these groups are natural allies for forensic pathologists and can help with resources—for example, embedding epidemiologists in the office to help with data reporting that could be bogging down forensic pathologists.

JOHNSON:
Let me ask the same question, but this time from a national perspective—what can be done there?

NOLTE:
There are some national level solutions to workforce that can involve federal agencies and professional societies.

For example, public service scholarships to get people to go into disciplines or to practice in areas that lack the medical staffing that they need. The U.S. public health service has done this for decades to provide physicians in urban areas, on Indian reservations, in other areas.

Loan forgiveness programs that could take a load off an apprehensive trainee who's looking at forensic pathology. Those programs could be run on a federal scale. They can also be run on a local scale. So, for example, Maricopa County in Arizona has used loan forgiveness as a way of recruiting forensic pathologists on to their medical staff, and they've been very successful with such a program.

Federal agencies should be looking at ways and exploring opportunities to reduce autopsy case work and thereby extend the diagnostic reach of the existing pathologists. So, for example, advanced imaging, as we talked about, has a potential to reduce casework.

But the role of advanced practice providers: advanced practice providers play a big role in clinical medicine in just about every discipline. Physician assistants, nurse practitioners—they've made up some of the shortage in primary care medicine, and they even practice in the specialties. They have played a role in the practice of pathology, in especially surgical pathology, but forensic pathology has been slow to use these types of physician extenders.

I think it's important for federal agencies to be able to fund infrastructure, technology transfer, and research in the utility and impact of some of these ways of extending the diagnostic reach of our existing forensic pathologists.

And I also think it's important for our professional societies who develop the standards and procedures for accreditation to start looking at how those standards and procedures could be adapted to incorporate advanced imaging, pathology assistants, and other methods of extending the workforce that we currently have.

JOHNSON:
You've talked about a lot of problems or challenges and some solutions at both the local and the national level. It's a lot of work to get this pipeline going again, it sounds like.

If you're a state or territorial health official dealing with a pandemic, what in this area would you prioritize? Let's say you wanted to try and do something—what could you do right now, given how busy you are otherwise?

NOLTE:
State and territorial health officials depend on data, on mortality data, that's generated by medical-legal death investigative agencies. They depend on it. These agencies conduct important surveillance, and that surveillance is used to judge the success of prevention and intervention programs. So, they should be looking for what they can do immediately, and they should be looking what they can do collaboratively over the long term.

Some of the things they can do immediately is help by putting an epidemiologist into a medical examiner-coroner office to help facilitate getting the data that they need.

They can be advocates because state and territorial health officials have access to their legislators, to their governors, and they should be advocating to make the salaries competitive in these offices to be able to retain the forensic pathologists they have and to be able to attract new ones.

They can immediately do an assessment of the quality of the work environment that an office has; and if it substandard, they can be the advocates that the state make it right as soon as possible. If they find their forensic pathologists are conducting autopsies in funeral homes, that's a really bad sign and they should be immediately advocating that they have the correct professional work environment—now.

So, there are many things that they can do immediately. Some things take a little longer to do but are not on a very long timeline.

Could we do better if we used our academic health systems to help us? Do we have medical examiner agencies or coroner offices that are just adrift? Are there ways that we could leverage our academic health systems so that our learners can see the practice of forensic pathology and potentially be recruited into this discipline? And, when they do so, the forensic pathologists who are working then in those environments have the ability for consultation and collaboration that enriches their practice, makes them more accurate, and more support of larger projects?

JOHNSON:
It sounds the little bit like we're behind the eight ball. So, what happens if we don't get in front?

NOLTE:
I think there's a lot of risk.

First of all, we're looking at increasing numbers of cases, especially due to the opioid epidemic and drug overdoses. You know, we went and hit 90,000 deaths in the last year. Those are a lot of cases, and right now we're looking at offices that are so swamped that many of them can't handle those cases according to our professional practice standards. They don't have the resources to perform the autopsies or get the level of toxicological evaluation; and when we reach that point, then the data that everybody is making decisions on is compromised.

It's compromised. So, we don't really know whether we have 90,000 or more than 90,000 if people can't handle them effectively in their offices. And then, we have less information to be able to judge whether what we were doing from a public health vantage point or from a public safety point is making an impact.

So, there's a lot at risk. And I just used opioids and drug overdoses as an example; but, you know, you can take a frame shift and say infectious disease and infectious disease surveillance, and are we recognizing the cases we need to recognize to protect the public? It's the same model.

So, there's a lot at risk for public health officials, and I would hope that they would be very interested in supporting medical-legal death investigation because that provides all of their data for unnatural death—all of the suicides, all of the homicides, all of the accidents, all firearm violence, for example—and it provides a lot of the data for the natural deaths, especially maternal mortality, child mortality.

And if we continue to have a shortage of forensic pathologists, not only will our data be compromised but the availability of these pathologists to participate in state-level committees—child fatality review, maternal mortality review, infectious disease death committees, all of those sorts of committees that require a forensic pathologist to be present, to help advise the process and the interpretation of the data—can be compromised if they're spending all of their time performing autopsies and have very little room to breathe.

So, I think we're looking at a crisis. I think COVID and the opioid epidemic has made what was a longstanding problem into a crisis; and I would hope that we can get state and territorial health officials, and individuals in the medical-legal death investigative systems, and other stakeholders together—along with federal officials who I know are already concerned about this issue—together to start looking at expeditious ways of solving it. Not just through the workforce, but through other processes as well that I described earlier: how do you change the practice of forensic pathology? How do you extend the reach of forensic pathologists? What sort of changes need to be made to the discipline?

JOHNSON:
Wrapping up, give us your best argument for tackling this problem now.

NOLTE:
In brief, forensic pathologists investigate deaths to serve the living and, therefore, it is important for everybody in our community that we have viable, skilled, comprehensive medical-legal death investigative offices to be able to protect the health of everybody, to be able to get the information that the public health officials need and the public safety officials need to make sure we have a healthy citizenry.

JOHNSON:
You've been listening to Public Health Review.

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This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.