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Forensic Pathologist Shortages: Context and Considerations for State Public Health Agencies

October 06, 2021

The opioid epidemic has exacerbated the shortage of board-certified forensic pathologists, presenting a major workforce challenge for public health systems. Forensic pathologists are licensed physicians who have completed additional training in anatomical and/or clinical pathology, along with a fellowship in forensic pathology. These professionals typically operate within medical examiners’ or coroners’ offices, or within servicing autopsy centers. Forensic pathologists investigate deaths, perform forensic medical autopsies, and determine the cause and manner of death for many scenarios, including sudden or unexpected deaths, deaths among mothers and infants, and deaths due to suicides, overdoses, work- related incidents, and infectious diseases. The standards adopted by the National Association of Medical Examiners (NAME) require autopsies when drug intoxication is presumed, and particularly when investigating and certifying opioid-related deaths.

The recent rise in drug overdoses and other traumatic deaths (e.g., suicides and deaths resulting from motor vehicle crashes) has led to an increase in the number of deaths that need to be investigated and autopsied. Given the shortage of forensic pathologists and the limited resources available, this increase jeopardizes accreditation and certification efforts and threatens the health of the individuals working in the medicolegal death investigation community. NAME recommends that forensic pathologists perform no more than 250 autopsies each year, with the maximum burden never to exceed 325. Surpassing this level will “seriously impact the work or adversely affect the health and safety of the public or agency staff,” resulting in the loss of full accreditation. As more people die from drug overdoses, more deaths need to be investigated and autopsied and state and local jurisdictions need more qualified professionals to fill this void.

The shortage of forensic pathologists did not begin with the opioid epidemic. In 2004, NAME held a forensic summit to inform Congress on service provider needs. The opioid epidemic has impacted this already fragile system and highlighted the ways in which the existing workforce lacks capacity to respond to major public health crises. A robust forensic pathology community ensures timely and accurate autopsies. Accurate autopsy findings inform programs and practices by identifying trends in disease and death and by helping to support quality assurance for families and hospitals. Unfortunately, many states have a difficult time trying to fill forensic pathologist vacancies since student loan debt, lack of training programs, lower salaries, and anticipated excessive workloads contribute to individuals choosing other specializations.

Federal Considerations

  • Increase visibility for established grant programs and expand these programs to assist with infrastructure development, particularly in regionalized systems, in order to optimize service delivery across state lines.
  • Expand visa programs like the Conrad 30 waiver program to retain forensic pathologists trained in the United States. Identify forensic pathology as an area of critical workforce shortage needs.
  • Develop and support loan forgiveness programs for forensic pathologists working for public health, education, or government agencies.

State Considerations

  • Increase funding for forensic pathology salaries. Forensic pathologists are typically public employees with lower salaries than pathologists working in hospitals or the private sector.
  • Increase funding for forensic pathology fellowships.
  • Increase access to accredited forensic pathology programs. In 2017, for example, the University of Rochester Medical Center partnered with Monroe County, NY, to establish a one-year forensic pathology fellowship program.
  • Create more loan repayment assistance programs. Officials in Maricopa County, AZ, developed a plan to recruit and retain forensic pathologists by offering qualifying medical examiners $25,000 in loan assistance annually.
  • Enhance forensic office operations by investing in instrumentation, including imaging technology. These investments can help improve the workflow, ensure that forensic offices meet the expected medical standards for diagnostic needs, and boost workplace morale.
  • Collaborate with forensic offices in utilizing J1 and other visa programs by recognizing forensic pathology as a critical medical shortage area and need.
  • Engage public health mortality surveillance partners in the national violent death reporting system (NVDRS), the State Unintentional Drug Overdose Reporting System (SUDORS), sudden death in the young (SDY), and other programs by supporting positions (e.g., epidemiologists) and embedding them within the offices of medical examiners and coroners. Data from the source is more robust, and partnering produces increased awareness, more rapid detection of emerging trends, and greater support for accurate and timely surveillance, intervention, and outcomes.
  • Support regionalization of forensic pathology services across state lines similar to other medical service delivery programs within a state. Maintaining local, robust forensic autopsy programs minimizes transportation costs, family and law enforcement issues, and promotes local public health surveillance efforts.
  • Promote greater visibility of forensic pathology in medical schools and pathology residency programs. Informational sessions, promotion, and early introduction to forensic pathology gives medical students the opportunity to learn more about this field.
  • Engage with state attorneys general offices and governors’ offices since forensic autopsy is critical to aspects of criminal justice.
  • Apply for grants, such as the Coverdell National Forensic Science Improvement Grants Program from the National Institute of Justice which funds grants to help improve the field of forensic sciences, including educating and training forensic pathologists.

Conclusion

Though the shortage of forensic pathologists is heightened due to a rise in drug overdose deaths, the shortage is not novel, nor will it end if drug overdose deaths decline. The lack of forensic pathologists has national implications and affects many other areas of public health, such as suicide, child deaths, maternal and domestic violence deaths, work and product safety deaths, emerging infections, and natural disasters. Public health plays an essential role in collaborating with the medicolegal death investigation community to implement strategies to alleviate this issue. State health officials can help to raise visibility by working with existing partners, such as state university systems and state attorneys general, identifying new partners, and elevating the issue to federal partners.