By - April 26, 2023
The practice of pathology as a specialty starts before the birth of an individual when prenatal testing is performed, transitions to a specialist pathologist that examines the placenta, includes every single laboratory test and tissue biopsy a person receives across their lifespan, and may end with a post-mortem examination. Every aspect of the diagnostic spectrum is crucial for a healthy life; however, at the end of life, should the circumstances of a death be suspect, the forensic pathologists and team combine a complex analysis of a crime scene with the post-mortem examination details to assist the medicolegal system in achieving justice.
If a patient needs a skin biopsy or gastrointestinal tract biopsy,or a core needle biopsy of the breast, there are often many choices depending on where the patient lives. If the services of a forensic pathologist are needed, choices become extremely limited. Let’s understand why.
It is estimated that there are around 500 forensic pathologists practicing actively in the United States which is one forensic pathologist per 638,000 people.1 The general pathologist rate is one pathologist per 20,000 people. With between 7,200 and 8,400 deaths per day in the United States, that means each forensic pathologist would have to deal with 14 to 16 deaths per day (e.g., reported, autopsied, etc.). However, that assumes this distribution is “perfect,” which it, unfortunately, is not.
The forensic pathology examination rate is between five and 10 percent, which equates to one to two examinations per day per forensic pathologist, if and only if, the distribution was even. In reality, forensic pathologists are most often concentrated in high population areas (i.e., New York, Los Angeles, Chicago, Houston, or Phoenix) and it would follow that these should be the busiest units. However, Miami, for example, comes in at #44 by population, but has one of the busiest forensic pathology units in the country, almost equivalent to Houston. San Juan, Puerto Rico, which is even smaller by population than Miami, has an equivalent number of cases to Houston because this unit covers the entire island of Puerto Rico; yet, they have one-third the staff of Houston.
Looking at this challenge another way, the top 20 cities in the U.S. for murders do not include the top five cities by population except for Chicago. Thus, while healthcare in general aligns pathology and laboratory services with populations, forensic pathology distribution and needs are highly dependent on criminal activity which simply does not align logically with other pathology services. One estimate is that at least 1,200 forensic pathologists are needed in the United States to meet the minimum requirements for service coverage. On average, about 400 new pathologists enter the workforce annually and less than five percent of them choose forensics as a specialty. With a gap of more than 500 pathologists (more than double the number we have now), it becomes obvious that this specialty is in crisis.
Several studies have been performed and multiple reports have been written about why the specialty is in crisis. These have highlighted decreasing entry into the specialty as well as early departure from the specialty. For the former, competing lucrative specialties and decreased emphasis on autopsies in general are common pain points. For the latter, challenges have included lack of fiscal, physical, personnel, and supporting resources and/or physical and mental burnout. ASCP, in collaboration with George Mason University, the National Association of Attorneys General, and the Montana Office of the Medical Examiner, engaged in an effort to further evaluate these challenges and look for feasible, practical solutions that would ultimately lead to increased forensic pathology workforce.
One of the first pieces of information we produced and distributed was a flyer on loan repayment programs specifically for forensic pathology (more than four different programs) as well as pulled the data on the current pay rates for advertised forensics pathology jobs—which was $100,000 USD more than what is quoted as the national average. Often there is a misconception that other medical specialties are more lucrative. In reality, the salaries being offered for forensic pathology are closer to the pathology average, with the added benefit that student loan repayment is possible. It’s important information to help encourage trainees choose this specialty—but they have to be aware of it. .
The next step in evaluating challenges was the completion of a survey with an initial round of contact gathering to ensure that our sampling would be representative of the workforce. This included medical students, pathology trainees, practicing pathologists, and pathologists’ assistants as well as coroners, law enforcement prosecutors, and judges. We then sent a detailed survey with questions specifically to certain groups. This data was helpful in formulating more involved questions for which we held a series of focus groups for open discussions about the overall challenges. The survey included questions about the general forensic workforce, groups focused on career pathways, pressures on current pathologists, and supporting staff issues.
From the feedback in these focus groups, we learned about one particular challenge that was not necessarily new but was recounted to be much more prevalent and problematic than we understood; namely, the widespread microaggressions toward individuals who profess interest in forensics as a specialty. These microaggressions were experienced as early as high school and college and were most common during the residency selection process and during the residency years. A general aggression toward the practice of pathology which discourages medical students from choosing it as a career was common. During residency, very aggressive anti-forensics comments were stated to have changed the trainee’s pathway away from forensics and into another specialty very often. These microaggressions not only came from non-pathology physicians (most commonly toward pathology in general), but also came from pathologists directly against forensic pathology selection. Our take-home lesson from this information was that negative experiences for students and trainees heavily influence their choices. We also learned that very positive experiences, as early as high school, guided students and trainees toward forensics.
With these observations in hand and reviewing the prior work and recommendations of other organizations, ASCP was reaffirmed in the concept of providing positive experiences in forensics for pathology trainees, which was part of the original grant submission in 2020 as well as discussed in the surveys, focus groups, and working groups in 2021 and 2022.
To make this program a reality, ASCP is setting aside funding for up to 10 residents in 2023-2024 and additional residents in 2024-2025 to do one-month rotations in forensic pathology laboratories primarily in rural/non-major urban locations with the goals of A) providing a positive elective experience in forensics, B) demonstrating the highly variable and dynamic ways in which forensic pathology can be practiced, and C) creating role model pathways for trainees to choose forensic fellowships and careers.
Many other interventions are needed to assist the specialty of forensic pathology in recovering towards a suitable workforce and ASCP continues to seek opportunities to work with our in-specialty and outside of specialty partners to achieve this goal.
Chief Medical Officer for ASCP