Monday, September 29, 2014

"Working Stiff" Book Club Discussion Questions

1. Many reviews and press events about Working Stiff list Judy Melinek as the sole author, even though the book is co-authored by T.J. Mitchell. Do you think this is due to his role as a homemaker? Would Judy's appearance in the media standing by her writer-husband detract from her status as a strong female media figure? Is Judy a “character” the press wants to explore in their stories, even outside the confines of her character role in her own book?
2. What role does New York City play in the book? Is the City a character? If Dr. Melinek had pursued her post-residency training in another city, could she have written a book about her experience? How (apart from her work after the World Trade Center disaster) would training in another city have changed the story?
3. Dr. Melinek took notes and kept a journal every day of her training in 2001-2003, yet Working Stiff is not structured chronologically. Why is this? What is gained from the book's case-based structure? What has been been lost—and what have the authors compromised—in choosing to tell a non-linear story?
4. T.J. worried while writing Working Stiff that the book might read like a hagiography of Dr. Charles Hirsch, and the OCME staff as a whole. Was he right—is Dr. Hirsch a saint, or a real character?
5. What role does the theme of parenting play in the book? Does being a parent make Dr. Melinek a better medical examiner? Was T.J.’s role as a full-time stay-at-home dad important to the story? How does being a parent influence how you do or your colleagues do their job, or affect others you work with?
6. Does Working Stiff have a story arc, or is the book just a collection of interesting if disparate death stories? Does it matter? Does a memoir need a structural arc?
7. What was the most interesting forensic fact you learned in the book? Is this what you expected a medical examiner's training to be like? How is the authors’ portrayal of forensic pathology different from its portrayal on television?
8. Did you wish after reading Working Stiff that you had heeded Judy’s advice, “you don’t want to know,” about stories of terrible deaths? If so, did this desire change with time, after you had finished the book?
9. Do you feel that Judy’s opinion of suicide as "a goddamned selfish act” is too harsh? Do you think it reflects the accepted medical opinion of her peers? Did reading the book change your attitude toward suicide?
10. In the United States 50% of all suicides are effectuated by gun and 50% of all gun deaths are suicides. States with highly restrictive gun control laws have far lower rates of suicide than states with lax gun control laws. These numbers include all types of suicide, not just suicide by gun. Do medical examiners have a civic duty to speak up about highly contentious political issues having to do with death, such as statistics on gun deaths and the effectiveness of gun control?
11. Working Stiff has been described as a “brisk” and “a quick read.” Is is too quick? Would you have liked to read more stories about the various manners of death we explore in the book, even if that meant some of them would become repetitive of others you had already read? Would a longer book have caused you to lose interest somewhere in the middle?
12. Judy & T.J.'s youngest daughter Dina, who is currently 9 years old, is extremely miffed at being excluded from the book. "Not being born yet" was not considered a sufficient reason for this oversight. It wasn't even good enough that we put her in the acknowledgements—because, as Dina says, "nobody reads those." Did you read the acknowledgements, and do you agree with Dina? Do you currently appreciate Dina? Should we write a sequel, "Working Stiff II: Revenge of the Stiffs," to placate her?


Please leave your comments or notes of appreciation for Dina below.

Thursday, August 21, 2014

"Partial Autopsies Yield Partial Answers"

"Partial autopsies yield partial answers" Dr. Charles Hirsch taught me as a young doctor during my forensic pathology fellowship training in New York City, in 2001-2003. This was one of scores of aphorisms we called "Hirschisms," which he employed to instruct us about forensic pathology. Another one was, "Don't confuse the autopsy with the death investigation."

Both come to mind this week in the wake of the release of the findings of the second Michael Brown autopsy, conducted by Shawn Parcells and Dr. Michael Baden. The body diagram they released to the press in the New York Times has now been altered into the "Hands up! Don't Shoot!" pose and is trending on Twitter.

The wounds are clustered closer together, so it must be "realistic," right? 

No. 

This is click bait—a picture that you can retweet easily without thinking about it much. This "tweaked" diagram is a grossly inaccurate portrayal of the victim's body position. The horizontal graze wound near the elbow is missing entirely; the top of the head wound doesn't make sense unless the victim is leaning forward; and the diagnonal graze wound on the right thumb would not occur if the right hand were up in this way—the graze wound has to be in line with the gun barrel, which means the hand was possibly extended forward toward the officer. That's assuming you trust the diagram.

And that's where my experience as a forensic pathologist and death investigator makes me ask a few questions:

1. Why was this diagram from the second autopsy—this evidence of the wounds on the body—even released to the public? The original autopsy diagram, the one prepared during the first autopsy by the St. Louis County medical examiner's office, is still sealed. So are the photos, scene data, and other evidence the district attorney will rely on to decide whether to prosecute the police officer. In all homicide cases, evidence such as this diagram is kept sealed so as to not influence potential witnesses who might see it in the press and change their testimony. Why release crucial evidence that could scuttle that prosecution? 

2. How reliable is this diagram? As I wrote in my recent OpEd on CNN.com, gunshot wound interpretation is not always easy. Parcells and Baden have opined that there were "at least 6 gunshots"—but without knowing the number of rounds fired, the number of casings and bullets recovered, the condition and location of those bullets, and the possible witnessed positions the victim was in, how can they say that with any certainty? What if the same bullet grazed the thumb and then re-entered the body, causing another wound? This diagram alone doesn't tell the whole story.



The diagram reproduced in the New York Times and elsewhere has both Parcell and Baden's signatures at the bottom—but which one of them made the diagram? And why are there no other details about the individual wounds on it? Why have they not noted the location from the top of the head/right of midline, wound size and shape? Where are their notes about soot, or stippling, or other trauma besides the gunshot wounds? The body diagrams I prepare during the course of a forensic autopsy are a whole lot more detailed than this; I need those details in order to accurately dictate my report after I finish the autopsy and get out of the morgue.

3. How reliable is the second autopsy?
There have been recent reports in the press that forensic technician Parcells has no credentials or accreditation, and misrepresents his experience.  Following allegations that Parcells did the autopsy alone, a doctor/blogger in PathologyBlawg.com interviewed Parcells. Parcells affirmed that he alone examined the body on 8/15 before it was embalmed; Dr. Baden was not yet in Missouri at that time. Two days later, after the body had been embalmed, Dr. Baden performed the second autopsy.

There is a big difference between the examination of Michael Brown's undisturbed body during the first, legally-mandated autopsy, performed by the St. Louis medical examiner, and the follow-up examination done days later on his washed and embalmed cadaver. In the embalming process, preservative fluids are injected into the arteries and organs using a sharp tool called a trocar. The trocar pokes holes in the organs. The preservative fluid in the blood vessels pushes the blood ahead of it to the site of any injuries. These changes, which we call "embalming artifact," can exaggerate the size and shape of injuries. 

Even if Dr. Baden, a board-certified forensic pathologist, looked at photos of the injuries taken prior to the embalming, the orientation and quality of the photos taken by the technician would influence his interpretation of the findings. Autopsy means "see for yourself"—and there is no substitute for seeing the undisturbed body for yourself if you are going to be offering opinions with legal ramifications.

Monday, August 11, 2014

Expert Mistakes

"An expert is someone who knows some of the worst mistakes which can be made in a very narrow field."
Niels Bohr

When I review others' reports and find mistakes I always try to learn from them because it is always easier to learn from others' mistakes than to make and learn from your own.

No one is immune to mistakes. It is what makes us human. The question is how do we, as scientists and experts, deal with our errors? Do we ignore them? Deny them? Or do we delve into the reasons why they occurred and make a change? And can we accept that by making a change in policy or procedure we will be opening ourselves up to future attacks by attorneys who will use the change as a basis to invalidate our previous opinions?

What are some of the worst mistakes? The worst I've seen are the result of arrogance. As an expert and legal consultant one needs to be confident and project that confidence when testifying. But knowing the facts of your case and showing proficiency in analyzing and conveying those facts is different from insulting or tearing down an opposing expert, criticizing the person instead of their opinion (ad-hominem attacks). I've been on the receiving end of those with opposing counsel making fun of me for having gone to Harvard or for my dress ("fancy"). Generally I know that if they are attacking me personally it is because they don't know how to attack me based on the facts of the case. I also know that the more obnoxious they get the more they will alienate the decision makers - the jury.

I have seen world-renowned experts, confronted with inconsistencies between their previous and current testimony, or between their testimony and a recently published article get defensive and even aggressive. They respond to legitimate questions with bluster and arrogance. Nothing turns off a jury more. The best way to deal with a direct attack is to address the specific issues at hand and simplify it for the jury. Explain to them why the case the attorney is asking about is different from the current case and how interpretations in science can vary based on these crucial differences. By the time the expert is done explaining, the jury will have either forgotten the attorney's challenge or gotten so wrapped up in the explanation of the facts of the current case that they will be right back along agreeing with the expert.

But how does an expert learn to keep her ego in check? The best way is to hang around people who know a lot more than you do. By teaching residents and medical students and working alongside staff in a university setting you are constantly barraged with questions that force you to challenge your assumptions and stay up on the scientific advances that drive the peer-reviewed medical literature. Take challenging consult cases: by sparring with attorneys on high-profile cases you are going to be confronted with sharp criticism and you'll find that you can't just rely on your experience and training - you need to stay current and sharp. And finally, go to professional meetings. Nothing humbles me more than attending an AAFS or NAME meeting, and sitting in lectures about the cutting-edge research others are conducting, or the challenging cases that others have successfully investigated. I can't sit for more than 10 minutes before having that "shoulda coulda woulda" feeling about some of my own cases. Yet at the same time, when I leave the conferences, I feel invigorated. Forensic science can be incredibly isolating, especially if you are the only doctor in a small rural Coroner's office. Lunching and dining with colleagues makes you realize that there is camaraderie and support; that we may not always agree on the best way to interpret an injury, or certify a death, but we can come together, break bread and do what scientists do best: collaborate.

The next NAME meeting is: Sept 19-23, 2014 in Portland, OR
The next AAFS meeting is: Feb 16-21 in Orlando, FL

Monday, July 14, 2014

"Cutting Corners"

Is it common for coroners or forensic pathologists to cut corners in a death investigation if a case does not look like foul play was involved?  Several visitors to this blog have asked me this question recently, as part of their research into forensic science.  Usually those inquiring have had direct contact with a Medical Examiner's or Coroner's Office - and did not find that institution particularly forthcoming. Office policies require death investigators to be careful about divulging information on open cases, and sometimes cases can be "pending" for several months while the pathologist awaits toxicology reports, microscopic slides, scene investigation or incident reports. This can be frustrating and even infuriating to the deceased's family members. They are the ones who have to plan the funeral, and answer inquires while dealing with their own feelings of grief and even guilt about the death while the case is still "pending additional examination." The law allows you to bury a body with a death certificate that says "pending" under "cause of death," but that is cold comfort to the family which has to tackle the inevitable question - "What happened?" - over and over again. A death certificate that says "Hanging" and "Suicide" may not be welcome, but it is an answer.

Coroners and forensic pathologists are two different groups of people. Coroner's deputies are death investigators (often part of a law enforcement agency, like a sheriff's office) while forensic pathologists are the doctors who do the autopsies. Both can "cut corners," yes - but in different ways. A Coroner's deputy might cut corners by not visiting the scene; by not examining the scene thoroughly, either in order to save time or because they are tired (many death investigations are at ungodly hours); by trusting the reports of the people at the scene about what happened without confirming whether those reports are accurate. The death investigation doesn't end when the deputy returns to the office and writes up the case. Frequently they have to complete their investigation, or ask others to, by getting medical records, police reports or questioning other witnesses who were not at the scene when they picked up the body. 

A forensic pathologist might "cut corners" by doing an incomplete or partial autopsy; or by rushing through the case and by not following up with police or Coroner's investigators when the story being given does not match up with the injury on the body or the presumed cause of death. This takes time. Coroner's deputies get paid per shift and FP's in a coroner system get paid per case. There is no financial incentive for the doctor or the deputy to invest extra time in investigating a case. Many offices are understaffed due to budget shortfalls, so there is always plenty of work and not enough people to do it. A deputy has to be efficient with his/her time; so if a case looks like something routine, such as an overdose or a suicide, you might see them cut corners in the interest of working speed.

Yet speculation frequently follows an overdose. Generally, people who use drugs and alcohol are on the margins of society, hang out with unsavory or unreliable "friends," some of whom may have criminal pasts. This fuels funeral-parlor rumors that foul play was involved when the person dies of an overdose. Generally, the only way the police or coroner can confirm that foul play was not involved is with a thorough death investigation. But the investigative and autopsy findings also have to be articulated to the family. Coroner's staff are not necessarily medically trained and may not be effective communicators, so families might seek out other sources for answers. That other source is sometimes me - and I am always glad to serve as a consultant, but only after asking the person calling whether they aired their concerns with the Coroner's office or with the police. I also ask whether the family member had spoken to the original pathologist who did the autopsy. Frequently they have not.  Sometimes if they go back and speak to those people who were directly involved with the death investigation, they will find out that the investigation was actually more thorough than they initially thought, or was not completely documented in the limited materials that were initially released to them.

Frequently I hear about families finding out about other peoples' suspicions at the time of the funeral. Unless the people fueling the speculation have direct knowledge of what happened, I would be cautious about putting too much faith in rumors. Family and friends often invent or exaggerate the importance of certain events in order to make themselves or others feel better about a death. I have investigated cases that were clear-cut suicides, where the deceased even left a suicide note, the family was understanding and seemed at peace, but then speculation at the funeral made them doubt the coroner's findings and suspect murder by an estranged lover or the roommate who found the body. Denial in the face of a death is a powerful (and expected) reaction - but entrenching that denial by piling doubt upon doubt is harmful to the grieving and healing process. I spend many hours counseling these families and I am grateful for my role in helping them find closure, and while I understand why well-meaning people can sometimes unintentionally cause more grief, it still pains me to watch.

What can be done about this? Well, if you are attending a funeral and have no idea why the person died, don't ask the family "what happened?" You'll find out soon enough. I love the Jewish tradition at a shiva (the equivalent of a wake) to bring food and not speak unless you are spoken to. When my father died the sustenance was appreciated and I was glad not to have to talk to anyone. If you feel really sad and want to share that with the bereaved you can always go with "I'm sorry for your loss," though I personally prefer sharing a happy story about something the deceased did that meant a lot to you or made you smile. That will have resonance and truly give comfort. If you are a family member and have been told things that disturb you about the circumstances surrounding the death of a loved one and are starting to have concerns, start by calling the officer who gave you their card at the death scene or informed you of the death. Tell them what others are saying, and ask them to help you have some closure. They may refer you to the forensic pathologist who did the autopsy, or maybe they will just reassure you that a thorough investigation was already done. If you don't get the answers you need, you can always ask to speak to their supervisor or to the pathologist yourself. In most cases, you will eventually be able to find someone to answer your questions, but please understand that death investigations take time. Just because you haven't heard back from the Coroner's office doesn't mean they have forgotten about you or about the case. The doctor may be waiting for the lab results before proceeding further. The Deputy Coroner may have received no replies when calling people to follow up on your concerns. Find out who the lead investigator is on the case, and what their hours are. If you call the office once every two to three weeks during their shift and always ask to speak to the same person, you will be able to get a progress report on what is going on with the case. I hope this helps you find closure. 

Monday, June 2, 2014

You Gets What You Pays For: Forensics Edition

Recently in the news,  North Carolina Medical Examiners were criticized for violating State law for not examining bodies or doing forensic death investigations in sudden or suspicious deaths that fell under their jurisdiction. In a five part series published by the Charlotte Observer, which contains heartbreaking testimonials by family members who were harmed by inadequate or incomplete death rulings, the Chief Medical Examiner for the State, Deborah Radisch MD, pointed out that North Carolina pays 84 cents per capita for its death investigation system, compared to the nationwide average of $1.76. "You get what you pay for" said Dr. Vincent DiMaio, the retired Chief Medical Examiner of Bexar County, TX, where the death investigation system costs a respectable $2.30 per capita.

Meanwhile, in Maine, the backlog has gotten so bad that they won't even take the time to measure it, the Chief is retiring and they are worried they won't find forensic pathologists to do the work. Why? Underfunding again. Yet while some economists recognize that autopsies are a public good and should be funded by the government, like lighthouses, getting adequate funding is difficult. Since death investigation is run on the county level the investment rests on county supervisors and executives, who are more interested in spending on services for living voters. This is source of the "medical examiner cycle," described by Dr. Shapiro in the Maine Press Herald article: offices get neglected until there is an embarrassing screwup; then heads roll and Chief is let go or demoted. Money gets freed up to recruit new staff, get accreditation, but as soon as the office becomes successful, fully staffed, well-run, and out of the news, the cutbacks begin and the cycle starts again.

What about Federal funding? Well a current Federal government report on forensic pathology points out that "under current Federal policies, ME/C are effectively ineligible for direct Federal funding and cannot receive grants from the Department of Health and Human Services (including the National Institutes of Health [NIH]), the Department of Justice, or the Department of Homeland Security." Coverdell grants, which offices are eligible for, are mentioned in this report but they cover equipment, accreditation and certification; they don't cover staffing or autopsies. The more understaffed an office is, the less likely it will have a person on staff who can dedicate the time required for grant application, paperwork and expenditures. So once an office is at the low point in the "medical examiner cycle" it is unlikely to be able to get out using Coverdell grants alone - just wait until the inevitable political embarrassment that will get the office some funding.

What can we do to prevent this and bring stability to the field? We need a Federal effort to help local counties fund and support their death investigation facilities with matching funds. Eligibility must be contingent on a minimum per capita investment by the local agency, with adjustments based on inflation. The matching funds for accreditation are the carrot but there needs to be a stick as well. One suggestion would be ineligibility for federal law enforcement funding support if the office is part of a Coroner and/or ineligibility for public health research funding if it is a public health agency. What I have seen in over 10 years as a public servant is that unfunded mandates do not work. It is not enough to require accreditation and training. There needs to be funding to support it. When there are reliable, well-paying jobs in the forensic sciences, students will enter the field and there will no longer be a lack of forensic pathologists. There is plenty of interest in forensics, but little motivation among physicians to take a high-profile public sector job for less money than they can make with fewer years of training. If you fund it, however, they will come.

Thursday, May 1, 2014

"I Think the Nursing Home Killed Him!"

I occassionally get calls from families requesting I perform autopsies on a relative because the family was concerned that the care in the long-term care facility or hospice was a contributor to the death. Many of these calls come from out of state because people find my blog on the internet, or were referred by an attorney who may have consulted me in the past. Here is some general advice for those of you who have concerns that the care at a nursing facility was in any way responsible for the death of your loved one.

First of all, instead of contacting a forensic pathologist, contact a medical malpractice attorney first. There are attorneys that specialize in medical malpractice litigation against hospitals or care facilities and many of them have in-house nurses, physicians or other specialists who can go through the medical records to see if anything looks amiss. Before meeting with the attorney ask if you should bring a full copy of the patient's chart(s) with you for their review. Sometimes there are several facilities involved: a hospital, nursing facility and hospice. Most attorneys will want a complete set of all the records to get a sense of the complexity of the case.  Make sure you write down all your recollections of what the doctors and nurses said or did that concerned you and the dates (if you remember them). When you meet with the attorney, these notes will help you remember what happened, and they may be disclosed to opposing counsel if you ever get deposed, so keep them clear of extraneous notes or unrelated private information.

An attorney can guide you in deciding whether you need an autopsy. The attorney will also know local practitioners that are reliable and good at both performing an autopsy and testifying.  Performing an autopsy is considered the practice of medicine in most states so it is best if the attorney gets someone who is licensed in your state. The more local the pathologist is, the less the cost will be to you, because of travel fees. If you do not want to sue, but just want to know exactly what the cause of death was, consider having the autopsy done at a hospital where the patient recieved medical care. Many teaching hospitals will do these autopsies for a reduced cost or for free on inpatients because the autopsies are used to teach pathology residents in training. But if you are concerned about trauma or malpractice, it is best you get a forensic pathologist who is board-certified in forensic pathology by the American Board of Pathology. Most importantly, if the death is in any way due to trauma (a subdural, fall from bed, a hip fracture) or there are documented allegations of abuse or neglect, it is required to refer the case to the local Coroner or Medical Examiner and have them perform the autopsy. If you get resistance from the local Coroner because the hospital reported the death as "natural" then you should notify them of the trauma, and you may need to file a police report or call adult protective services to file a complaint about the abuse or neglect in order to encourage the Coroner to do an autopsy. This is important because only the Coroner or Medical Examiner's autopsy has the legal standing to prompt a potential criminal investigation. Also, most hospital autopsies don't collect toxicology so they won't be able to address questions about over-medication. That said, your perception of "over-medication" in a dying hospice patient, may actually be appropriate end-of-life care, so please consult a professional in order to interpret prescriptions, toxicology reports or pharmacy records.

Be aware that sometimes an autopsy can't answer all your questions. An autopsy is very good at showing what was happening at the time someone died, and figuring out what caused the death. If a wound has healed or a disease has been treated prior to death, the pathologic findings may have resolved and not be immediately visible at autopsy, but the consequences to the patient should be evident in the medical chart. Therefore, make sure the pathologist who does the autopsy has access to the records ideally prior to the performance of the autopsy, or at the very least prior to completion of the autopsy report. 

Finally, before you embark on the arduous task of delving into the death of a loved one, be aware that malpractice litigation can take many years and the process of litigation itself can be a stressor on the family that can prolong the grieving process, delaying closure. If there are other members of your family that disagree with your assessment and want you to "let it go" you may want to talk to them and see if litigation is really the best path forward for everyone involved.  Make sure you have plenty of emotional support throughout the process either from friends, relatives or spiritual/religious counselors. It will help you heal.

Monday, April 7, 2014

FAQ#3: Interested in Becoming a Forensic Pathologist? Some Advice forStudents

One of the most common questions I get is "What advice do you have for me if I want to become a forensic pathologist?" These are my answers for students at different levels of training:

For high school students:

First and foremost you need to focus on getting good grades in high school so that you can get into a good four-year college. Make sure you are doing well in your math and science classes. If you are not sure you want to be a doctor and want to pursue other aspects of forensic science (criminalist, technician) I would suggest you research college programs in forensic sciences. George Washington University and Florida State University have well-respected programs, but there are others, so when you are touring and interviewing colleges in your junior and senior year, make sure you tell them about your career interest and see what programs they have to offer.

For college students:

If you are in college, I would focus right now on pre-med requirements and get those out of the way first. Meet with your pre-med advisor early to make sure you have the list of all the requirements and get the classes complete (and with good grades) before your applications for medical school are due.

See if you can find some part-time volunteer or paid work in a laboratory or at the your university's closest affiliated medical school. You can start by looking up professors at your own institution, typing up your resume and a short cover letter saying that you are looking for part-time research work, and dropping it in their mail slot or stopping by office hours. You can pick professors you like who have taught you, or just browse the on-line profiles of educators in your field of interest on the university website. Before you meet with the professor, read (and try to understand) some of their papers and see if their research inspires you. Don't be discouraged if the scientific papers go "above your head." Look up the terms, or meet with a graduate student advisor who can help you understand them. And don't be discouraged if the professor says "No." If the prof is too busy, has too many students and turns you away, ask if he/she can refer you to a colleague. Working or volunteering at a lab will give you much -needed hands-on experience while you are in college, and will allow you to build a relationship with your professor so that you can then get recommendations for medical school or another laboratory job when you graduate.

The American Academy of Forensic Sciences offers grants to college students to attend their meetings. You can go on line and look at the student resources at their website and see if you can attend the annual meeting. I would recommend holding off on applying and going to their meetings until you are a junior or senior in college and about to apply to medical school or graduate school in the sciences. That way it will look good on your resume when you apply to medical or grad school.

For medical school students:
Pathology is usually covered in the second year of most medical school curriculums in the United States. While taking the classes, get to know your teachers and ask them if there is an elective rotation in pathology that you can take in your third or fourth year of medical school. Talk to pathology residents in your institution and ask them who the best professors are to work with, then find a part-time lab job. If you can even spare a few free hours a week after school to help with experiments or do library research for another doctor, you will build a good relationship and get exposure/mentorship that no classroom experience will match. Find out if there is an elective rotation at the medical examiner or coroner's office, or just call up the local office and see if they are willing to take you on to do some volunteer work. This will give you the exposure you need to see if this is the right field for you.

For pathology residents:
Most pathology programs have a required forensics rotation. Compared to other subspecialties, forensic pathology fellowship programs are not that competitive. Some remain unfilled every year, but the best ones fill early. New York City requires you do a rotation at the office if you want to be considered for fellowship, generally in September or October in your second year of residency (after you have some autopsy experience). Other good fellowship programs are in Albuquerque, NM, Miami, FL and Baltimore, MD. I suggest you call the programs you are interested in and schedule a rotation month there, regardless of whether it is required. It will give you an opportunity to meet the forensic pathologists, see their work and learn what you need to pass the boards.

Become a member of NAME and AAFS and start reading their publications. They have discounted membership rates for residents and there are job ads there as well as fascinating journal articles that will inspire you. 

Foreign Medical Gradutaes:
First of all, contact your medical school and see if they have information that might be helpful. The American Medical Association has information about the ECFMG (the examination needed to get an American medical license) on line at http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/international-medical-graduates/practicing-medicine.page?


Once you pass the ECFMG test you can apply for an Anatomic Pathology residency in the United States. I would contact the American Board of Pathology (ABP) http://www.abpath.org and the American College of Graduate Medical Education (ACGME)https://www.acgme.org/acgmeweb/ about residency programs. Every year there are are residencies in pathology that don't fill so if you're open to working anywhere in the US you will likely be able to find a program. In your first year of residency training you should do a rotation at the Coroner or Medical Examiner's Office and apply for fellowship. 

For all:
Forensic pathology is not the only path to a career in the forensics sciences. Not everyone has the grades, ambition, or money to get them through the 8+ years of schooling required for a medical degree. There are other fields in the forensic sciences that may be right for you and these include Forensic Nursing, Forensic Toxicology, Crime Scene Analysis, Forensic Psychology, Medicolegal Death Scene Investigation, Law Enforcement or litigation. If you are interested in any one of these fields there are many forensic science professional organizations on the internet that can help guide you. Many of these organizations have free or reduced fees for attending their annual conferences specifically targeted toward students or non-members who are interested in the field. These include:

The American Academy of Forensic Sciences


The National Association of Medical Examiners


International Association of Forensic Nurses


American Board of Medicolegal Death Investigators