Makeshift morgues were necessary back in 2020, when COVID-19 lacked a vaccine and was killing so many people that hospitals and funeral homes couldn’t keep up. But two years later, they were still in use in Baltimore—for a different reason. In February, according to news stories at the time, at least 200 bodies from the medical examiner’s office sat in refrigerated truck trailers parked inside a parking garage for weeks. There was simply nowhere else to put them—because of a shortage of forensic pathologists.
There were so few forensic pathologists in the city—medical doctors who perform autopsies to examine sudden, unexpected, or violent deaths—that autopsies were backlogged. Bodies couldn’t be examined, and laid to rest, as quickly as they usually were. Dr. Victor Weedn, the chief medical examiner in Maryland at the time, says turnover in the profession had reached about 70% in 2021 and was only getting worse. COVID-19 didn’t help, and neither did the fact that homicides in Baltimore reached a 50-year high for the month of January, and overdose deaths set a record in 2021. The office was underfunded and the staff was underpaid, says Weedn, which led some workers to leave for higher salaries. The office of the chief medical examiner ultimately called in the Federal Emergency Management Agency to provide workers to clear the backlog. “With relatively few staff stretched to the limit, anything else can make the whole system snap. And that’s kind of what happened,” says Weedn, who resigned later in February and now works in Washington, D.C.
The crisis in Maryland was indicative of a widespread but little-known aspect of the worsening problem of physician shortages. Roughly 750 forensic pathologists are working full-time in the U.S., but about twice as many are needed to cope with the rising caseloads, says Dr. Kathryn Pinneri, president of the National Association of Medical Examiners. The shortage has been going on for at least a decade, she says, but it’s especially drastic now: on Nov. 10, there were 55 forensic-pathologist job openings posted on the association’s website, while only about 40 people become board-certified forensic pathologists each year, she says.
A growing number of drug overdose deaths, rising violent crime, and the COVID-19 pandemic have all demanded more from this small specialty workforce. One 2019 survey found that 37% of forensic pathologists do more than 250 autopsies a year, which is the maximum number the association recommends they complete. Forensic pathologists say the increased workload can compound the stress of working in a field where they must constantly face the risk of trauma, which can lead to burnout and early retirement.
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Without action to mitigate forensic pathologists’ workload, Weedn warns that they could skip autopsies and miss details, which could lead to consequences like less accurate death counts from the drug overdose crisis, including not identifying the mixture of drugs in the patient’s system. “Every autopsy is a node of information,” he says. “If you haven’t identified the true cause of death and simply call it a heart attack, you’re doing everybody a disservice.” It could also come at a personal cost for families, he says. “It’s really important to families to know why people died. The autopsy is really how you answer the lingering questions.”
Forensic pathologists play a crucial role in both private lives and public health, says Dr. Joyce deJong, who works in Michigan as a medical examiner: a physician charged with investigating deaths, who is typically a forensic pathologist. Through autopsies, they offer answers to families of people who die unexpectedly, and in some cases, without an obvious explanation. Autopsies are also essential to help law enforcement sort natural deaths from homicides. Often, they provide valuable data that inform public-health actions. The U.S. implemented safer baby crib standards after medical examiners reported a slew of infant deaths, for instance, and determined that parts of certain cribs could come apart and trap infants’ heads.
Because of the current national shortage of forensic pathologists, these answers are taking longer than usual to reach.
The shortage has forced some forensic pathologists to alter their practices, with some offices taking longer than the recommended 60 to 90 days for returning autopsy results, Pinneri says. Some offices have also begun to forego autopsies in cases where the decedent appears to have succumbed to a drug overdose. Such shortcuts raise the risk of important information being missed—for instance, if a person dies from a genetic anomaly while using drugs. “If we find some genetic condition, or other condition that might run in families, I think it’s important that the family is aware,” says Pinneri. “I think we’re going to miss natural disease processes that are going on in individuals that use drugs.”
Shoring up the workforce
To alleviate the forensic-pathologist shortage, the first priority is to recruit young doctors to join the field, Pinneri says. It can be a tough sell: becoming a forensic pathologist requires about nine years of education after college (medical school, a pathology fellowship, and a year of forensic pathology training).
An added challenge, says deJong, is that medical school students don’t imagine spending their career with deceased patients and must be persuaded it’s a viable (and attractive) career option. Compared to other specialties, she often tells them, forensic pathologists tend to work more reasonable hours—although at times they might be called to examine a crime scene in the middle of the night. The variety can also be a draw: one day, you might autopsy a homicide victim—the next, an elderly person who died of natural causes. So is the sense of satisfaction of helping people at the worst moments in their lives. DeJong says she receives an email each year from a father to thank her for explaining the sudden death of his baby.
All medical students at Western Michigan University, where she works, view at least one autopsy during their four years of med school, says deJong, and she tries to demonstrate that forensic pathology can be fascinating and rewarding. Recently, she says, she showed students an autopsy of an elderly person who was found at the bottom of three steps. It seemed a simple case of a heart attack, until the doctor got to the decedent’s brain to reveal a subdural hemorrhage—a sign that the person had died after hitting their head. Such information could be important both for the family, and for public health. “I think there’s valuable information in knowing how many elderly people are dying from falls, and what we can do to help,” says deJong.
Forensic pathologists have found new ways to make their work more efficient. For instance, some offices—including deJong’s—purchased CT scanners for the forensic pathologists for the first time in the last few years, which enables forensic pathologists to spot clues like trauma faster. Increasingly, offices have also digitized their records, which allows forensic pathologists to do parts of their jobs remotely.
Maricopa County, like many other parts of the country, has had a greater need for autopsies in recent years: in 2021, more than 6,000 bodies were admitted for examination, up from less than 4,000 in 2010, according to the county’s 2021 annual report. A significant driver is the increase in drug-related deaths, which rose from 783 in 2010 to 2,171 in 2021. However, Maricopa County has sped up its reports despite receiving more cases: in 2021, the average case was completed in an average of 52 days, down from 135 in 2016. Dr. Jeffrey Johnston, chief medical examiner for Maricopa County, credits a string of programs with lessening the workload and helping Maricopa County attract talent in a tough labor market. As forensic pathologists are typically public sector employees, their pay tends to be lower than for other specialists. Students leave medical school with an average of $203,0000 in debt, which adds to the pressure to join a high-paid profession, says Johnston. To attract these students, Maricopa offered an incentive in 2017: up to $100,000 off their student debt, dependent on how long they work for the county. “It helps us to stand out from other places, and we know it eases the burden,” says Johnston.
During the pandemic, Maricopa also tried two new strategies to strengthen their workforce. The county hired forensic pathologists based in other offices to work in Maricopa on a part time basis, and hired physician assistants to review medical records and build reports in cases in which an autopsy isn’t necessary. Johnston says the physician assistants have reduced forensic pathologists’ workload by about 20%, and helped to give them peace of mind that they don’t need to sacrifice the quality of their work to keep up with the caseload.
“It caused a lot of strife with the families who want closure, and with other public officials who need things,” says Johnston. “We’ve kind of gotten off this roller coaster that we used to be on.”
Nationwide, the problem is still far from solved. Even if more students pursue the career, the shrinking workforce of both doctors and forensic pathologists means there just won’t be enough people to fill the need, says deJong. In the long term, she says, it will be important to use new techniques, like investing in new technologies and hiring more assistants trained to help in tasks like autopsies. While some forensic pathologists may balk at the changes, she says, the field is already using these techniques—and they’re not going away.
“We are not going to get enough forensic pathologists. It’s just not going to happen,” deJong says—so people in her line of work must figure out how to do their jobs with fewer resources. So many are counting on them, she says. “We don’t do surgeries, we don’t write prescriptions. Our work products really are answers.”
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Contributor: Tara Law