Forensic Pathology – It Takes Guts

Session 210

Dr. James Gill is a community Forensic Pathologist. Take a dive with us into the work that he does in discovering what brought patients to his table. Out of training for 24 years now, James also talks about some unique things happening in the forensic world including being involved in court cases.

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[01:11] Interest in Forensic Pathology

James recalls working as an intern in the crime lab one in Connecticut back when he was in college. His interest in crime lab was what drew him to medicine. Then in between his first and second year of medical school, he also got to do a summer internship at the Connecticut office of the chief medical examiner, helping out with research as well as with autopsies. From there, he was firmly committed to doing forensic pathology.

With his father being a defense attorney and his mother a nurse, James used to watch him in court, handling murder trials among other things. So he obviously got his early exposure to the legal and medical side of things from his parents. Plus, the fact that he likes science and figuring things out, everything just fit together for him.

[02:50] Some Myths & Misconceptions Around Forensic Pathology

One of the most common misconceptions around forensic pathology is that they only do homicide autopsies all day. But James clarifies this is only a very small part of their work. Their main work being, around public health.

'The very, very small fraction of the deaths that we investigate are homicides.'Click To Tweet

They handle cases like sudden infant death syndrome (SIDS), drug intoxication deaths, as well as sudden natural deaths in young people that are unexpected. They provide a lot of data and information to many other stakeholders and people from agencies like the Department of Transportation, Department of Labor, and Child Fatality Review Committees.

James adds they spend time with one of their local trauma centers, where they review trauma-related deaths that came through the hospital. They provide information gathered from the autopsy so they can learn from that. And when they see the next patient that comes in with a similar set of circumstances, they could look for something different or treat something differently.

And so, while people seem to think they only deal with the dead, they actually work coming from a perspective of how they can help the living. That being said, they play a big role in bereavement for families as well.

Ultimately, the multifaceted nature of their work is something people may not grasp because not only do they deal with homicides. They also deal with public health, as well as teaching, testifying in court, dealing with the police, and dealing with families.

[05:03] Understanding Their Role in Bereavement

As forensic pathologists, they also play a role in helping families negotiate one of the most terrible times in their lives. When they’ve just lost a loved one, they often have questions about it. Why did they die? Did they suffer? Was it quick? Was it slow? What happened? Was there foul play involved? These are some of the questions they try to answer to help these families understand and hopefully accept what happened.

A lot of times with hospital deaths, there’s an abrupt transition where the person dies and the physician speaks to the family for a few minutes– and that’s it. At that point, the family may be in shock and they may not have really thought about things. It takes some time for them to process things and start thinking about everything. And so, as they’re coming up with all these questions in their mind, they try to fill that gap and help answer those questions.

[06:26] Traits that Lead to Someone Being a Good Forensic Pathologist

James points out the importance of being inquisitive and wanting to figure things out. These are people who enjoy solving problems and find the unknown very challenging and stimulating.

It’s also an important trait to be a very detailed oriented person. Focus on the details and realize those details can be very important – they can actually make or break certain cases.

Empathy is another key trait that makes someone a good forensic pathologist since you’re going to be dealing with families.

'Being a good teacher is also important because not only for families and for students, but when they testify in court, a big part of testifying in court is teaching.'Click To Tweet

As a forensic pathologist, you also have to have that teaching ability. Sometimes, you may have to explain very complicated medical issues to the jury so they can understand them. Hence, you need to have the ability to translate medical jargon into words that they can understand. That way, they can make an informed decision about what happened in a particular case.

[07:49] A Day in the Life of a Forensic Pathologist

His schedule varies from day to day as far as autopsy versus paper. In a typical week, a medical examiner in Connecticut may be on autopsy two or three days of the week, and then they’re on paper the other day.

On paper days, they’re not going to be doing any autopsies. They’re either working on paperwork or doing some teaching or going to court.

On autopsy days, they have a morning conference at 9 am. They go through all the data and all the deaths that have come in the previous 24 hours.

They review any scene photographs and then divide the cases up. They go down and start doing their autopsy. Generally, most autopsies are done by noon or 1 pm.

Sometimes, they may have to get X-rays first or wait for the police to come. Then they will take photographs of the body. And then they stary their external and internal examination of the body.

They tend to limit it to three autopsies per day per doctor. Some days, it may be one, and on other days, two or three. Some days, it could be a case of a complicated multiple gunshot wound. Some days, it may be a very straightforward, young person who overdosed on fentanyl.

'You never know what you're going to see.'Click To Tweet

And then in the afternoon, they’re dictating their cases. They have another conference at 3 pm to discuss the day’s cases and review them in a group. They talk about any teaching points or any interesting findings or questions they may have. Then they finish up paperwork and other reports.

[09:42] Life Outside of the Hospital and Taking Calls

James says it’s pretty much a nine-to-five type of job. They have investigators who are on 24/7. So they go to the scenes for them and they handle most of the hospital calls.

That being said, they have a very reasonable lifestyle. They could take calls on a weekend, maybe once every third weekend. They come in, do the autopsies, and they’re done.

They also take a handful of overnight calls a month that they take from home. They act as a backup for the investigators if they have a question about whether or not a certain death needs to be brought into the medical examiner’s office.

They also get calls from agencies responsible for organ and tissue donations. Because if a person has been declared dead by, say neurologic criteria where they’re brain dead, and they want to try and do proceed with organ donation. If that’s a medical examiner’s death, they need to clear that with them. And so, they get the call maybe at 3 am and they usually allow that to proceed because it’s too important of a thing for them to stand in the way.

[11:18] Getting to the Scene

I asked James if there are situations where, as medical examiners, they also go out to the scene, and he says this depends a lot on the jurisdiction. There are some offices where the medical examiner will go to every homicide because they may not have their own investigators.

And if there’s something unusual, if it’s a plane crash or multiple homicides, usually, they’ll send one of the medical examiners to that as well. But in their case, their investigators are very well-trained and experienced. They always have a medical examiner backup so if they have any questions, they can always reach somebody.

[13:19] Thoughts on the Astroworld Tragedy

With what happened in Houston during the Astroworld concert where at least eight people passed away, there are few reports saying that someone was injecting people with a substance.

James says it will be investigated by the medical examiner’s office because there are sudden unexpected deaths that are potentially related to trauma. And they could look at puncture wounds carefully, but usually, what they would be more interested in is what’s in the body.

So they would have to undergo full toxicology testing. Now, they’ve also seen similar situations like this before with big crowd surges. And usually, what causes death is asphyxial death from chest compression. People in the front just can’t breathe, and they die standing up because they’re so compressed.

As a medical examiner, you have to do a full autopsy. You exclude other types of injury and other intoxications. And then with the history and the circumstances, you end up formulating your final diagnosis.

[15:36] The Training Path

After your three or four-year residency in Anatomic and Clinical Pathology, you need to do a one-year fellowship in Forensic Pathology. That’s typically at a medical examiner’s office or a coroner’s office where you’re working as a medical examiner. You’re going to have your own cases, initially, you’re gonna have a lot of supervision, as you’re going to be doing your cases with another medical examiner.

As you become more independent, you could already do homicide or handle people who die in fires and drug overdoses. James says you have to do as many cases as you can so you can get comfortable with doing autopsies. You also have to make sure you understand what needs to be documented, what you need to look for, and what the body is telling you.

'You want to be able to see and do as many different types of deaths as you can so you become very comfortable in doing those autopsies.'Click To Tweet

Once you start practicing as a medical examiner, you’ve got a lot of those cases already under your belt, so to speak, and you’re more comfortable with what comes along now.

They’re always still going to be challenging cases and unusual cases. And that’s part of the interest because they’re always learning and teaching themselves new things. But the purpose of the fellowship is to really grow and grasp what you need to know to become a forensic pathologist.

[17:32] The Need for Forensic Pathologists

James says there are many fellowship spots that go unfilled each year. Part of the reason is maybe there’s just not enough funding for those spots. There are some very competitive programs, traditionally, in New York, Baltimore, Miami, Texas, and Chicago.

“Right now, there is a severe workforce shortage for forensic pathologists.”Click To Tweet

James claims there are not enough forensic pathologists in the country to cover all those jurisdictions. In fact, currently, there are only about 500 or so board-certified practicing forensic pathologists. For all the jurisdictions to be covered, they would need 1200-1300.

There’s competition now to get these forensic pathologists because some offices are raising their salaries. The federal government is also doing some draft legislation looking to help fund more forensic pathology fellowship programs, as well as provide some loan forgiveness for student loans for people who go into forensic pathology.

“The good side about forensics is the salaries are increasing and there's this potential loan forgiveness program.”Click To Tweet

[20:04] Other Special Opportunities

James adds there are other ways to supplement your income. There are a lot of forensic pathologists who will do some private consulting, or they’ll do per diem work. They may go for a few days a month, and work in another office because of the shortage.

A lot of offices need this per diem help. And so a lot of junior forensic pathologists can actually supplement their income pretty well by doing some of this per diem work.

For consulting work, there are either criminal or civil attorneys, med mal cases, for example, or even just criminal cases, where someone’s looking for a second opinion. Or they need someone just to review the autopsy report just to make sure, for their due diligence, that something hasn’t been missed, and that everything’s been done properly.

“There's medical, legal, or consulting work available for forensic pathologists out there.”Click To Tweet

[23:01] Overcoming Bias Against DOs

James says the medical examiner he hired is a DO. And regardless of whether you’re a DO or MD, what they’re looking for is for you to have passed all the tests first and foremost.

[23:38] Seeing How Pathology Helps Patients

James cites the book, Guiding the Surgeon’s Hand, written by an incredible surgical pathologist. And you can see how the diagnoses and the information that the pathologist gives to the surgeon, or the treating clinician really has a big role in the treatment of that patient.

[26:10] What He Wished He Knew Before

James wants to assure people that forensic pathologists are actually really normal people. And that’s because he had this misconception before.

'Forensic pathologists are very normal people. They have families and they have typical hobbies. They're great people to work with.'Click To Tweet

[27:31] The Most and Least Liked Things

What James likes the most is that every day, it’s something different, and you never know what you’re going to see. Every day you’re dealing with different people, with the police, with prosecutors, with families, with public health people, and with students.

He likes being able to solve problems and trying to figure things out. And this is the perfect job because he gets to do those. He’s also constantly learning from every autopsy and every time I testify in court. And he’s still learning something to make himself a better forensic pathologist.

What he likes the least, on the other hand, are the staffing and funding challenges. Many short-staffed offices run the risk of cutting corners, which warrants them to really guard against this to make sure they’re still doing quality work. Plus, they’re seeing increasing numbers of opioid deaths and homicides so they don’t have enough staffing.

Fortunately, most of the policymakers out there are starting to realize the importance of the work they do, which is something James is glad about.

[30:35] How Insurance in Forensic Pathology Works

James explains the insurance is absolutely a different flow of money. Families don’t pay anything for a medical examiner’s autopsy. But if they want to get a copy of the report, there’s usually a charge for that.

Typically, forensic pathologists work for some government body and so, they’re funded by that government agency.

There are also some instances when private groups contract with a government agency so they kind of do the work privately. But are employed by the state of Connecticut, as it relates to his practice. His salary is then going to be governed by the state of Connecticut and by labor unions.

'Insurance doesn't reimburse for hospital autopsies.' Click To Tweet

If the treating doctor wants to have an autopsy, and they get permission from the family, the insurance company is not going to pay for that. James thinks that’s probably one of the reasons for the decrease in the number of hospital autopsies. And so in many places, the medical examiner has become the autopsy person of the community.

[33:49] Major Changes Coming to the Field

James says more and more offices are now getting radiology equipment such as CAT scans and MRIs into their facilities.

They’re also now doing more molecular testing to diagnose molecular abnormalities that can cause sudden death. They could now look at why people maybe develop a DVT and pulmonary embolism. Or maybe they have hereditary thrombophilia.

And this has greatly helped the way they solve cases. For instance, young people in their 20s, who suddenly drop dead, and you do the autopsy. You find nothing and they’ve got a completely normal heart. But with molecular testing, they’re able to find that they have a genetic abnormality in one of their sodium-potassium channels responsible for this.

That’s not only important information for the certification of the death but also important information for the family to know because a lot of these deaths will run in families. And so now, families can get tested for that specific mutation to see if they carry it. Again, another example of how their work can help the living.

[35:49] Final Words of Wisdom

If he had to do it all over again, James says he still would have chosen to be a forensic pathologist. After 20 plus years of doing this, he still enjoys coming into the office every day and trying to figure it out. He still enjoys doing autopsies.

Finally, if you’re interested in this field, James urges you to call your local medical examiner’s office. Ask if you could come for the day and just watch an autopsy. And if they say no, give him a call or send him an email. Then he would gladly make a phone call or drop an email to the office to allow you to come in and see what they’re doing.

'We need people who are interested in forensic pathology to see what it's like. So then maybe they'll decide to go into it.'Click To Tweet

James says it’s important to have exposure very early in your first or second year of medical school, even college. In fact, they’ve been starting to speak to college students about forensic pathology. Because sometimes people don’t discover forensic pathology until even their pathology residency.