This piece is the first in a three part series on Forensic Pathology in the United States. I will focus on how death investigation works in this country, the critical role physicians play in the process, and how to fix the enormous shortcomings of our current system.
It is perhaps necessary to begin by distinguishing medical examiners from coroners. Coroners do not have to be medical doctors in most states, and are usually elected. Typically a sheriff or another member of law enforcement fills the role of coroner. The requirements for being a coroner vary, but in most states no intensive training is required. For example, in California (where I live), a coroner must take a 2 week course, after which he or she may write death certificates in traumatic injury cases. Coroners do not perform autopsies, but do have the final say regarding the cause of death. They may or may not send bodies out to contracted pathologists for autopsies, and may or may not follow the recommendations of the pathologists who perform the autopsies.
A medical examiner is, by definition, a medical doctor. He or she is usually board certified in forensic pathology with the American Board of Pathology. Becoming board certified requires 4 years of medical school, plus a 3-4 year residency in anatomic pathology, plus a one year fellowship in forensic pathology. Once this extensive training has been completed, the individual may perform autopsies and present evidence as a medical expert in a court of law.
In 2009, the National Academy of Sciences released a report entitled Strengthening Forensic Science in the United States: A Path Forward, which outlines how death investigation in the United States is conducted. The report begins in the following manner: “Recognizing that significant improvements are needed in forensic science, Congress directed the National Academy of Sciences to undertake the study that led to this report.” Clearly, the government saw that there was a need to look into the way forensic science is practiced. As it stands, each state and each county has a different system put in place for death investigation. The following map shows this patchwork of systems:
Unfortunately, this means that where an individual dies determines the quality of investigation into his or her death. Many factors contribute to the quality of the investigation, including whether there is adequate funding for the coroner and/or medical examiner’s office, and whether the physician performing the autopsy happens to be board certified in forensic pathology. There are no national standards for this; the National Academy of Sciences report mentioned above states that “the hodgepodge and multiplicity of systems and controlling statutes makes standardization of performance difficult, if not impossible.” There is no proficiency testing for the individuals who carry out these investigations, which results in incompetent practitioners being able to work unnoticed for decades.
Occasionally, court cases with heavy media coverage will bring the glaring need for standardization front-and-center. Horror stories abound about lost body parts, bullet holes being overlooked, wrongful convictions, murderers walking free as a result of botched autopsies, etc.
In cases involving police brutality, conflicts of interest often arise because elected coroners usually have strong ties to law enforcement. If an individual in custody is beaten to death, or if there is a police shooting similar to the one making headlines now in Ferguson, Missouri, do we really want the person in charge of the body and/or in charge of the entire death investigation to be an ex- or current police officer?
PBS Frontline: Post Mortem aired in 2011 and took a look at the problems mentioned above. This program featured two forensic science professionals who shared their opinions about the deplorable state of death investigations in the United States:
“In this country, many medical-legal offices are producing garbage.”
-Vincent Dimaio, M.D., former Chief Medical Examiner, San Antonio, TX
“It amazes me that such an important aspect of our government as medical-legal death investigation doesn’t have accreditation.”
-Ross Zumwah, M.D., Chief Medical Examiner, New Mexico
Clearly, we need to improve on our processes, and as future physicians and citizens we need to understand the importance of forensic pathology and death investigation, for the sake of our communities at large and for the sake of the families of those who have passed away. Our patients do not stop being our patients after they pass away; everyone deserves the right to a proper investigation surrounding the circumstances of their death.
References:
http://www.whitehouse.gov/sites/default/files/microsites/ostp/NSTC/forensic_science___may_2014.pdf
http://www.pbs.org/wgbh/pages/frontline/post-mortem/map-death-in-america/
http://www.pbs.org/wgbh/pages/frontline/post-mortem/
https://www.ncjrs.gov/pdffiles1/nij/grants/228091.pdf
https://www.youtube.com/watch?v=yFPW016ocXI/
I watched as any sliver of hope vanished from their eyes. They would not wake up from this nightmare. The moment my mentor delivered the diagnosis, I could feel the world take a 180 eighty degree turn for this family. It was as if their world froze at that moment. How could this be? The child looked so peaceful, fast asleep while hospital monitors blinked around her. Just a week ago, they were running around to sports practices and dentist appointments and going through the everyday motions that we consider to make up a normal life. I’m not even sure that this family was breathing at this moment. The room became deafening silent as all the color drained from their faces. The doctor proceeded to talk about what would happen in the days to come. What did this mean for their child?
So much of early medical education involves pouring over books and PowerPoints, trying to memorize as many details as possible. It is important to have that foundation of knowledge, but what I have come to realize is that there are rarely pure “textbook cases” because so much more goes into caring for a patient. One size does not fit all in medicine. This experience brought back the humanity of medicine. I witnessed how knowing and understanding patients enables a physician to be an advocate for their patients, a role I consider to be the most important of the many roles a physician takes. I can never come close to knowing exactly what these families are going through. I also can’t thank them enough for allowing me to be present during their most vulnerable moments, for taking time to talk with me for a brief period to get a glimpse of their journey. Ultimately, this experience was a reminder that the art of medicine can’t be discovered in textbooks. It is learned from our patients and the uniqueness that their individual journeys bring to each patient encounter.