Too Many Bodies, Too Few Forensic Pathologists

This story was corrected on Feb. 18. 2022, to clarify that the Virginia Office of the Chief Medical Examiner is not currently experiencing delays in processing cases and that it was the outgoing governor, Democrat Ralph Northam, who made a budget proposal to the Virginia General Assembly.

Faced with an overflow of bodies during the coronavirus pandemic, medical examiners around the country have had to add to their storage capacity.

Many have brought in refrigerated trucks or other kinds of mobile units. A few have created racking systems that allow for the vertical stacking of bodies. Some, such as in Los Angeles, are considering building additional permanent storage if the current excess of bodies proves a harbinger rather than a blip.

Dr. Jonathan Lucas, Los Angeles’ medical examiner-coroner, said he held off asking for additional resources last year because he hoped that the influx of bodies would ebb, even as he had to bring in 14 refrigerated trucks. As the third year of the pandemic nears, Lucas says he’s rethinking that. “Now I think we’re in a situation where I have no choice but to plan that this is not going to go away in the short term,” he said.

In Maryland, the backlog of cases awaiting autopsies has gotten severe enough that the state earlier this month asked for help from the Federal Emergency Management Agency, which agreed to dispatch forensic pathologists.

The overload at medical examiners’ offices across the country stems from two trends: More bodies are arriving at the offices, the result not only of additional deaths related to the pandemic but also an upward trajectory of homicides, overdoses and even traffic-related fatalities. And the country is simply not producing enough forensic pathologists to keep up with the workload, especially during the pandemic.

The workload in many places is delaying timely autopsies or leading pathologists to perform more autopsies than the 250 a year recommended by the field’s accrediting body.

“We do more than 250. Most do,” said Dr. Gregory Hess, chief medical examiner of Pima County, Arizona, which encompasses Tucson. “I think it’s hard for most offices to stick to that guideline nowadays.” He said caseloads in his office have been up about 20% during the pandemic.

Meanwhile, families must wait for the release of their loved ones’ remains or a final death certificate while autopsies, post-mortem examinations or lab tests are completed. Dr. William Gormley, Virginia’s chief medical officer, said while his office has not yet experienced those delays, he’s concerned that will change if he can’t hire adequate staff. “Having to carry over cases can be frustrating to families,” he said. 

“Some families understand this,” he said. “Many do not.”

Some medical examiners are asking for increased local or state funding. Some also are suggesting loan forgiveness and grant programs and more outreach for medical schools and even colleges to lure people into forensic pathology.

With caseloads in Virginia up nearly 20% during the pandemic, Gormley said he asked for six additional forensic pathologists in his budget request this year. Former Gov. Ralph Northam, a Democrat, cut that request in half in his budget proposal to the Virginia General Assembly, Gormley said.

In Texas alone, caseloads for medical examiners have doubled in the past five years, said Dr. Kathryn Pinneri, president of the National Association of Medical Examiners and the director of forensic services for Texas’ Montgomery County.

In Maricopa County, Arizona, which includes Phoenix, caseloads are growing at three times the rate of overall population growth, said Dr. Jeff Johnston, the chief medical examiner. “And we are one of the fastest-growing counties in the country,” he noted. He received additional money from his county during the pandemic to hire private forensic pathologists to temporarily assist with the workload.

Alongside that increased number of bodies being sent to medical examiners is a national shortage of forensic pathologists.

The title of medical examiner refers to professionals, usually doctors, who conduct examinations to determine a cause of death. Medical examiners often are forensic pathologists as well, but requirements differ among the states. Forensic pathologists have completed a medical residency in pathology and a fellowship in forensic pathology. During the fellowship, they receive training on autopsies and other techniques related to forensic evidence.

The United States has about 500 full-time, board-certified forensic pathologists, according to Pinneri’s organization. “The reality is we need about twice that number,” she said.

‘Capturing Fellows’

Only about a fifth of people who die end up at a medical examiner’s office, estimated Hess of Pima County.

Usually, the deceased are sent to the medical examiner if they died suddenly, violently or the cause of death is suspected to be unnatural or isn’t immediately evident, or if they hadn’t been under the care of a physician. The vast majority of the nearly one million Americans who have died of COVID-19 died in a hospital, so they were not sent for autopsy or post-mortem examinations. (A small minority of states require a medical examiner to issue all death certificates.)

Despite that, the pandemic has increased the number sent to medical examiners. Especially in the early months of the pandemic, many people died at home without a physician. So, too, did many people with chronic conditions who were fearful of going to the hospital or medical clinic, said Lucas, the Los Angeles medical examiner. Most of those cases likely ended up in a medical examiner’s office.

The federal Centers for Disease Control and Prevention reported that as of Feb. 16, in addition to the 914,000 U.S. deaths attributed to COVID-19, there have been another 131,000 deaths since the pandemic started that it classifies as “excess,” meaning that they exceed the number that would normally have been expected.

Overall, Lucas said, his office’s caseload increased nearly 35% since the pandemic hit. He estimated that about 40% of that increase resulted from overdoses, much of it fueled by the opioid fentanyl, 40% from natural deaths and 20% from homicides. A high percentage of those additional cases, he said, were from the city’s growing homeless population.

That increased workload came amid a shortage of forensic pathologists that began before the pandemic.

The National Association of Medical Examiners currently lists openings for more jobs than the number of forensic pathologists who enter the workforce every year. Pinneri said about 40 new forensic pathologists graduate each year, “which isn’t enough to keep up with the needs of the jurisdictions and the numbers of those retiring or going to part-time or just dying.”

During the pandemic, Pinneri said, the national association is relaxing its standard of 250 autopsies a year per forensic pathologist for accreditation reviews of medical examiner’s offices. The hope is that medical examiner’s offices can keep the numbers under 325 a year.

Forensic pathology requires even more training than most medical specialties: five more years of education after medical school, including a final year in a fellowship in forensic pathology, usually with a medical examiner’s office.

“I trained enough years I could have been a heart surgeon or neurosurgeon,” said Dr. Jeffery Barnard, chief medical examiner of Dallas County. But, because most forensic pathologists end up working in government rather than private practice, they are paid far less than those in other medical specialties.

ZipRecruiter estimates that a forensic pathologist earns on average just over $143,000 a year, compared with $248,000 for a general surgeon.

Not For Everyone

The competition to hire forensic pathologists is intense, medical examiners agree. “It’s kind of a struggle to stay staffed and remain competitive and recruit people,” said Hess.

The competition is especially fierce in landing fellows after their medical residencies in pathology. Those fellows represent the best opportunity for replenishing staff because they often stay in the offices where they train.

“Capturing fellows, that is our lifeline,” Lucas said. Trying to hire more experienced pathologists is generally a lost cause, which is why Lucas last year said he held off asking the county to fund additional positions.

“We may be understaffed,” he said, “but if I don’t have any applicants coming to me, how can I make a request for more people in good faith?”

Not everyone is cut out for the work, Barnard said. Dealing with homicides, suicides and overdoses is stressful. On top of that is the need to interact with the criminal justice system, which is not the norm for most medical disciplines.

“A lot of times you have to deal with lawyers and judges and then dueling experts,” he said. “Not everyone is built to withstand what goes on in the courtroom. A lot of people figure, ‘I can sit behind my microscope, make diagnoses, send out my bills and go home versus doing this kind of thing.’”

Now, medical examiners are trying to determine whether their increased workloads have become the new norm. Many are pessimistic.

“I do not believe that this shortage will resolve itself once the pandemic recedes,” said Dr. Sean Hurst, Oregon’s chief medical examiner. “The current crisis has been on the horizon for years, at both national and local levels.”

If the body count remains high, Pinneri said, it will be even more crucial to increase the flow of medical students and residents willing to pursue forensic pathology. That could mean creating loan forgiveness and grant programs similar to those set up to attract new doctors to rural and urban health care systems.

But Pinneri and other medical examiners say it’s equally important to expose residents, medical students and even younger people to the work of forensic pathology. Even residents may not get that experience, because while hospitals may have pathologists on staff, most forensic pathologists work elsewhere, usually in government facilities.

That is why some forensic pathologists, including Phoenix’s Johnston, do their own kind of outreach. He speaks at medical schools and invites students to visit his facilities and observe autopsies. The national association also distributes online lectures and webinars.

The field should be more attractive, said Dallas’ Barnard. “What we do is a whole lot more interesting than what hospital pathologists do,” he said. “No one asks at a cocktail party what a prostate biopsy looks like, but they all want to know about that homicide.”