Forensic pathology’s fate matters to all
February 2023—Whether you watched Quincy, M.E., like I did as a kid, or something more recent like CSI, many of us encountered pathology for the first time through a TV show. Watching Jack Klugman’s weekly adventures as the L.A. county medical examiner, Dr. Quincy, certainly had me intrigued about the specialty of pathology. While most of us work in clinical or anatomic pathology instead of subspecializing in forensic pathology, it’s the forensics field—and how it’s portrayed in TV and movies—that gives most of the general public the only insight into pathology they get in their daily lives. When people outside the medical field hear about a pathologist, they typically picture someone performing an autopsy and trying to figure out the mystery behind a person’s demise.
I bring this up to help highlight just one of the reasons that we should all care about the field of forensic pathology: It’s the lens through which the public understands the work we do. The CAP has a policy supporting the work of forensic pathologists, and works closely with their leading subspecialty professional association on regulatory and legislative issues that affect all pathologists.
Unfortunately, there is a huge discrepancy between the role that forensic pathology plays in the public imagination and the number of people who do this kind of work. For decades now there has been a shortage of forensic pathologists, and it’s only getting worse. According to a recent report to Congress from the National Institute of Justice, there are just 400 to 500 full-time practicing forensic pathologists in the U.S., less than half of the 1,200 experts needed.
This shortage comes as no surprise to us. After all, less than one percent of medical school graduates pursue pathology in general, and only a small fraction of those choose to specialize in forensic pathology. A 2020 publication in the American Journal of Forensic Medical Pathology from Victor Weedn, MD, and M.J. Menendez said that there were only 36 forensic pathology fellows in the U.S. in 2019.
Dr. Volk
Some of this trend has been attributed to a dramatic decline in hospital autopsies. According to that 2020 publication, autopsy rates have dropped from at least 50 percent in 1950 to less than five percent today. Many new hospitals are being built without morgues. There is a strong, but not necessarily accurate, perception that advanced imaging technologies have eliminated the need for autopsies. Another challenge is a lack of funding. Medicare, Medicaid, and private payers all agree that once someone is deceased, he or she is no longer covered by insurance. Autopsy expenses must be paid from shrinking hospital budgets or by the families of the deceased.
As private citizens, we should all care that there are enough qualified professionals available to perform scientific autopsies that may be needed to explain sudden unexpected deaths or even to inform our criminal justice system. As citizens of a representative democracy, we want as much objective information available to the criminal justice system as possible, and that is what forensic pathologists are trained to deliver.
And from a professional perspective, clinical and anatomic pathologists practicing in any number of different clinical settings should very much care about the fate of our colleagues in forensic pathology. We have seen this in other areas in medicine already: If there aren’t enough experts to perform important work, there will be a push to fill that gap some other way—often by reducing the qualifications needed to do it. We run the risk of having people with insufficient training assigned to perform forensic pathologist work. It is yet another threat to the scope of practice in pathology.
This kind of work goes well beyond findings related to any single death. Forensic pathologists have a huge role to play in public health. During pandemics, their expertise is critical to identifying trends about how people are dying. Their analyses during the COVID-19 pandemic about what the virus was doing to the bodies of its victims were essential in helping other medical professionals learn how to care for patients more effectively to prevent them from dying. Forensic pathologists also inform other big issues, such as shining a spotlight on the recent resurgence of syphilis in the U.S., identifying the drug overdose epidemic, or framing firearm-related deaths as a public health crisis.
How can we help? One of the most important things we can do is to help raise awareness about the forensic pathology career path among up-and-coming physicians. Even though forensic pathologists are so popular on TV shows, many people do not understand that these experts are physicians. Pathologists in academia in particular can help through their efforts as pipeline champions, introducing medical students to the field and getting them excited about the impact they can have as forensic pathologists.
Dr. Volk welcomes communication from CAP members. Write to her at president@cap.org.