Friday, January 9, 2015

A Forensic Primer for Journalists

Since the publication last year of my New York Times bestselling book Working Stiff: Two Years, 262 Bodies, and the Making of a Medical Examiner, I have found myself in the public eye as an expert in my field of forensic pathology. When a high-profile death investigation hits the news, journalists from all over the U.S., and occasionally other countries, call and ask me to "explain the autopsy"  to them.  
Autopsy reports can be daunting to read if you have not been trained in medicine, so when I have the time I will make an effort to put things into plain English for these reporters, just as I do for a jury when I work as an expert witness. In many cases, however, I find that professional writers and news analysts lack even the most basic knowledge about forensics.  
Here, then, are some definitions and guidelines that journalists or anyone writing about death investigations and autopsies should find useful.

1. A Coroner is not the same thing as a Medical Examiner
Both a coroner and a medical examiner perform forensic death investigation—that is, examinations on behalf of the public into the circumstances of any death that is sudden, unexpected, or violent. The crucial difference is this: A coroner is an administrator or law enforcement officer, and a medical examiner is a doctor. 
A coroner position is a political one. Coroners are either appointed by an elected official, or are themselves elected. In some counties, the coroner’s office may be a division of the sheriff's department. In some states, it's a branch of the state police.  The coroner is not a physician and does not perform the autopsy; he or she hires contract forensic pathologists for that job. The coroner is responsible for supervising the administrative aspects of the death investigation. The contracting forensic pathologist determines the cause of death (the disease or injury that killed the person), and the coroner determines the manner. Manner of death is a system of classification of the causes of death into categories. The usual list is natural, accident, suicide, homicide, and undetermined, though these may vary slightly by individual jurisdiction.  
Sometimes—historically rarely—the coroner will perform a coroner's inquest, a special court proceeding in which the coroner acts as judge. The coroner has subpoena power and can call witnesses to testify, to answer the coroner's questions, and also to present findings to a jury. Either the coroner or the jury decides the manner of death after a coroner’s inquest. 
A medical examiner is a forensic pathologist, a physician with specialized training in death investigation. In a medical examiner's office, a doctor called the chief medical examiner is in charge of both the death investigation and overseeing the performance of autopsies by other doctors, usually known as assistant medical examiners or deputy medical examiners. The decision of cause and manner of death determination falls on the deputy medical examiners, who receive guidance and supervision from the chief. Generally, medical examiners do not hold inquests.

To confuse things, some offices (like Los Angeles County and Santa Clara County in California) use the term "Medical Examiner-Coroner," and in some counties they refer to the death scene investigators as "Medical Examiners" even though they are not physicians. And, to complicate the term even further, in some areas "Medical Examiner" is also used to refer to doctors in general practice who do insurance physicals in disability claims, and who have nothing at all to do with death investigation.
Bottom line: Find out whether the office you are reporting on calls itself a "Coroner" or "Medical Examiner," and use that term. Stick to it. Don’t use the terms interchangably. It is a mistake to mix them up.

2. Homicide is not the same thing as murder. 
Homicide means "death at the hand of another." Intent is not a factor—only a volitional act is required to call a death a homicide. So if someone is playing with a loaded gun and accidentally shoots another person, the medical examiner or coroner will classify that death as a homicide. It’s up to the district attorney to determine whether it is in the state’s interest to charge the defendant with murder or manslaughter, or not press any charge at all.  
In some jurisdictions all motor vehicle fatalities are classified as "accidents" regardless of the driver's intoxication status, while in others, DUI offense deaths are mannered "homicide." The district attorney can still charge them as "vehicular manslaughter" or as "criminally negligent homicide" but those are legal determinations and don't change what the coroner will call it.  
Whenever a member of a law enforcement agency kills someone, whether it is an officer-involved shooting, a choke hold, or any other means of causing a fatal incident, the death is generally classified as a "homicide" because it is a death at the hand of another. Typically there is a review by the district attorney to decide whether the officer will be charged with a criminal offense. If the district attorney decides to charges the officer, a prosecutor will take the evidence either to a grand jury or to a preliminary hearing in front of a judge. The forensic pathologist who performed the autopsy will be called to testify as an expert witness in this legal hearing. The judge or jury will decide whether there is sufficient evidence that a crime was committed. If the judge or jury decides the officer was using deadly force within the guidelines of his professional judgement and training, then they will probably find that no crime has occurred. 
That fatal event is still a homicide. That’s what it says on the death certificate as manner of death, as determined by the coroner or medical examiner. But it is not a murder. Murder is a criminal charge, and calling a homicide a murder does not fall within the purview of the agency performing the forensic death investigation. That’s a job for the DA, judge or jury.

3. Don't confuse the autopsy with the death investigation
Deaths are only reported to the medical examiner or coroner if they are sudden, unexpected, or violent. Each state has laws that delineate what cases fall under the jurisdiction of the Coroner/ME, and each jurisdiction decides which cases get investigated, and to what extent. If the death is violent and suspicious, typically the police handle the primary investigation, and the medical examiner will incorporate their findings into the overarching forensic death investigation. The medical examiner will request the police reports and witness statements, and will even review the video of the incident (if there is one) if it helps in the determination of cause and manner of death. But not all agencies are willing to cooperate with the medical examiner's office, and it is not unusual that in high-profile cases, attorneys get involved, and the exchange of information slows even further.  
The autopsy pathologist can only tell so much from the dead body. Trying to figure out the cause of death from the dead body alone without knowing anything about the scene, circumstances, or medical history of the decedent is medical malpractice for a doctor like me. It would be like a surgeon coming in to perform surgery on an unconscious patient without the benefit of a physical exam, medical records or X-rays. 

So do not expect the coroner or medical examiner to release any information about the autopsy on a high-profile case—especially if it’s a homicide—as soon as the autopsy is done. The autopsy is just one piece of a long process that results in a cause of death determination. That process may, and in many cases must, take many months to complete.
4. "Pending" is not the same thing as “Inconclusive"
In many news reports (most recently the ones involving Joan Rivers's death—see http://www.cnn.com/2014/09/05/showbiz/joan-rivers/ ), when the autopsy is complete but the medical examiner has sent out specimens for additional testing, or needs more time to review the police reports or medical records, the preliminary determination after the autopsy will be that the case is "pending.”
Please, please understand this, members of the professional news media: “Pending" means you have to wait for the results. It does not mean "we don't know.”
A pending cause or manner of death also does not mean that the autopsy findings were "inconclusive.” Something is inconclusive when you cannot draw conclusions about it after all the information is available. In a pending case, we are all still waiting for that information before we can come to any conclusion. The autopsy itself may be very, very conclusive, but the medical examiner is not going to tell you that—because they are still working to complete the death investigation, and that will take some time. 
If at the end of the investigation the medical examiner or coroner says the cause of death is “undetermined”… Well, then and only then are you correct in writing that their investigation was "inconclusive." In Joan River's case, several months after the autopsy and the inaccurate early news stories calling the autopsy “inconclusive," the investigating medical examiner’s office reached a determination of both cause and manner of death. These were not inconclusive in the least: http://www.cnn.com/2014/10/16/showbiz/joan-rivers-cause-of-death/

5. The autopsy doesn't “show” or “tell" you anything. The expert does.
It always riles me when I read in the news that "the autopsy showed five gunshot wounds to the body, two at close range, and a single stab wound.” (For instance: http://www.slate.com/articles/news_and_politics/politics/2015/02/laquan_mcdonald_shooting_a_recently_obtained_autopsy_report_on_the_dead.html) No, the autopsy didn't show that. The forensic pathologist determined it. It is his or her professional opinion of the findings. A different forensic pathologist might look at the same body, or at the photos and scene investigation, and determine that, based on the position of the body, the five gunshot wounds were created by three gunshots. Two were bullet re-entry wounds. Oh, and that stab wound? It isn’t a stab wound. It’s actually a therapeutic artifact—a hole put in the body by the doctors in the hospital, during their attempt to save the decedent’s life. 
It is confusing to the public if you divorce the autopsy from the opinion of the practitioner, especially when there is a subsequent review of the findings, and they are found to be mistaken or misinterpreted. It also undermines the public trust in forensic scientists who do their best to interpret the injuries, but may not always be given all the information they need to do a thorough job. 
It is also confusing to the public if you get your hands on an autopsy report and regurgitate its findings without at least calling the pathologist who authored it, to request help in comprehending what exactly you are reading. If he or she won’t speak to you, please try another forensic pathologist. The lay public, whether journalists or their audience, do not have the experience or expertise to interpret most autopsy reports without professional guidance. That may sound paternalistic, but it’s the truth. There’s a good reason that forensic pathologists go to court to interpret their findings in person to juries, and even to judges—their findings can be obscure to anyone not trained in our very narrow and specialized field, and the conclusions we come to in forensic death investigations are important.
In most cases the coroner or medical examiner will release autopsy reports under Freedom of Information Act requests, but they may not have a public information officer who will be able to take the time to explain it all to you. Or the investigating pathologist may not want to go on the record interpreting the findings, and then get cross-examined on what some journalist wrote in the paper about that interpretation—especially if that reportage turns out to be inflammatory or erroneous. Your best bet as a journalist is to find another expert who will take the time to explain it to you so you get it right. 

6. The first legally-mandated autopsy done by the Coroner or ME's pathologist is an independent autopsy. Everything else is not.
“Independent" means not influenced by anything or anyone. During that first autopsy, the forensic pathologist collects trace evidence, has photographs taken, and makes incisions into the body that literally alter the evidence. Even if this pathologist were to face political or bureaucratic pressure to interpret the findings a certain way, the physical evidence of the first forensic autopsy will become public record and will be used in court, where it is open to unblinking scrutiny. So the Coroner's or Medical Examiner's autopsy is always an “independent” autopsy—even if their conclusions turn out to be wrong. It is the documentation and collection of the evidence from the whole body, the first time, that matters, and it is this process of collection that makes the forensic autopsy the only independent one. 
Any pathologist hired by attorneys, the decedent's family, or anyone else to perform a second autopsy is not "independent." He or she is a retained expert. That means if his findings are not helpful to the family's attorney, they don't have to disclose them. At all. 

The Coroner or Medical Examiner's pathologist doesn't have that option. They represent an agency which is legally charged with independently ascertaining the cause of death. They will be called to trial. Their report will be disclosed and argued over. That is the ultimate in quality control—legal transparency and cross-examination. If another public agency, like the Armed Forces Medical Examiner, reviews the original findings at the request of the family or because there is public outcry, that is a secondary review, and it is also no more "independent" than the autopsy performed by the coroner’s or medical examiner pathologist.
Forensic pathologists are doctors, not police officers. Autopsies are not "ordered by the police," or “done for the police," as was written repeatedly during the Michael Brown case in Ferguson, Missouri. Forensic pathologists are not in the business of covering up for anyone, even the police. While they may rely on good relationships with the police department in order to get the information they need to do their job, they are committed to doing that job properly, for very good reasons—if they do not, they will either lose that job, or ruin their relationship with their own boss (the Coroner or medical examiner) in order to please an outside agency (the police).

7. "Consistent with" does not mean "it's the only explanation”, and “appears" is not the same thing as “is.”
When an expert says that something is "consistent with" or that it "appears to be” something, that does not mean this is the only explanation of the forensic findings. Other explanations or interpretations may be plausible, or equally consistent with the physical findings. Sometimes the expert's preference for a particular scenario is contingent on the information that is available at the time, or on that expert’s own experience and training. 
Shawn Parcells, the forensic technician who autopsied Michael Brown under the hire of the Brown family and their attorneys, found this out when the final autopsy report showed that there was particulate material consistent with gunpowder in the wound on Michael Brown's hand. He and retained forensic pathologist Dr. Michael Baden had stated in public that all the wounds "appeared to be" distant range, but Parcells had not taken microscopic sections during the second autopsy he conducted. After Dr. Baden looked at the microscopic slides collected by the original forensic pathologist in the normal course of the first autopsy, he testified to the grand jury that the St. Louis County Medical Examiner's findings were correct.  (See: http://int.nyt.com/newsgraphics/2014/11/24/ferguson-evidence/assets/gj-testimony/grand-jury-volume-23.pdf page 38
The news reports surrounding this case made it seem that the forensic experts disagreed with one another. They didn't. It's just that they were asked different questions at different points in time. And when one of those experts used the word “appeared” about a finding that was not yet final, he was quoted and interpreted by many media outlets as speaking definitively instead.

Conclusion: So what should a journalist do?
- Consult a forensic expert. When you have a breaking news case and an autopsy report in hand that makes no sense, first contact the medical examiner or coroner's office that released the report. Ask if someone there will explain it to you. If they can't or won't, find a forensic pathologist who will.
- Read about forensic topics, and look up information in forensic journals so that you can become more fluent with the language the scientists use, and so that you will be able to challenge them with intelligent questions.
- Be careful how you quote the forensic pathologist. If the expert says "don't quote me" or "off the record," respect that. Scientists are protective of their professional credentials, and will be a lot more comfortable speaking with you on the record if they can see their quotes in context in the substance of the article before it gets out. Have them check what you wrote to make sure it wasn't taken out of context or misunderstood prior to publication. It is much better to get it right than to issue a retraction or correction—or to watch while the source you relied upon comes out in public and points out that you took the time to do your research, and then got the story completely wrong. 
It happens. Forensics is complicated, and sound bites are few. But always keep in mind that you are exploring a story about a dead human being. You owe it to that person—and to your audience, and to the public record—to get the details of the death investigation rigorously right.

Thursday, December 4, 2014

Finding a Qualified Forensic Pathology Expert

1. Is the pathologist certified by the American Board of Pathology?
This is the most important qualification for an expert witness in the field of pathology. Just because an expert claims to be "board-certified" does not mean he or she is. Not all board certifications are the same. The American Board of Pathology is the only board offering certification in forensic pathology in which the applicant has the following qualifications:
  • Graduated with an M.D. or D.O. Degree from an American College of Graduate Medical Education (ACGME) accredited medical or osteopathic school.
  • Licensed to practice allopathic or osteopathic medicine.
  • Completed a minimum of 3 years training at an ACGME accredited pathology residency program
  • Completed a minimum of 1 year training at an ACGME accredited forensic pathology fellowship program
  • Has passed qualification examinations in Anatomic Pathology and Forensic Pathology.
Be aware that there are experts who use degrees from on-line "diploma mills" and sham certifications can be purchased. Just because someone has a nice website or has been featured on television in a high-profile case does not make him or her an expert. Titles such as "Forensic Pathologist Assistant" or "Death Investigator" are not qualifications, and if someone is claiming to be a "Professor" it is good idea to check with the institution to make sure they really are on faculty. 

2. Where was the pathologist educated and trained?
Ask for the expert's curriculum vitae or resume. Don't be impressed by the multitude of pages, but look at the content. Have you heard of the universities? Do they have a good reputation? You might want to check with the institutions that the doctor did actually graduate with the degrees listed. If a doctor is not foreign-born but they chose to go to an off-shore medical school, it is sometimes an indication that they couldn't get into medical school in the United States. Foreign medical graduation alone should not concern you if the doctor has subsequently completed residency and fellowship in the United States and passed their Board examinations. It is important to look at where they did their fellowship training: the most prestigious forensic fellowship programs are either in large cities (such as New York, Miami) or part of a centralized State-run Medical Examiner's Office (such as in New Mexico or Virginia). There is also an excellent forensic training program through the Federally-financed Armed Forces Medical Examiner. But even programs with good reputations can undergo seismic changes if there is a scandal or the Chief retires. You can always Google search the name of the program along with the word "scandal" and see if any news reports come up with the expert's name on in. If you don't do this, opposing counsel definitely will.

3. Do they come recommended?
Few lawyers take the time to ask for references, but if you are finding an expert witness via the internet, or by using an expert witness referral service, it is a good idea to ask the expert for lawyers they have worked with recently. Only another lawyer can tell you if the expert was readily available, reasonably priced, easy to work with and understandable. The lawyer can also tell you whether jurors understood their testimony, since most pathologists don't get feedback directly from the people they are being hired to educate.

4. Are they currently practicing forensic pathology or are they a "professional expert"?
Many forensic pathologists who practice forensic pathology full-time at a County Coroner or Medical Examiner's Office still do some consulting as expert witnesses "on the side". A few work part time or do per-diem work at a County facility. However, there are several forensic pathologists who have retired or left practicing medicine completely and work as legal consultants full-time. The latter group can be problematic if they are out-of-touch with the standards and requirements of current medical practice, or are marketing themselves as "hired guns." Some have been forced to leave civil service because of ethical violations or political scandals.  Some have a national reputation but only take high-profile cases and don't actually perform autopsies any more. If you are hiring a "professional expert," make sure they are well-qualified, highly recommended, and have their background checked.

5. What is their "bedside manner"?
Many pathologists enter this field of medicine because they are more comfortable with dead bodies than with living people. Unlike academic medicine, where a pathologist has to have some teaching skills to maintain their appointment, forensic pathology is very attractive to introverted practitioners who like to work in solitude. Although all forensic pathologists are expected to testify in legal cases, and many are quite comfortable with it, that doesn't mean they are any good at communicating complex medical issues. So when you are on the phone with the expert ask yourself if they are understandable. Do they use "Med-speak" or do they explain the medical terminology to you as they talk? Are they personable, even charismatic? While some people are not good communicators over the phone but are very eloquent in person, if your first interaction with the expert is unimpressive you may want to schedule a face-to-face meeting to see if you can understand them better. But if you can't understand what the expert is saying - then neither will the jury.

6. What is their area of expertise?
Not every forensic pathologist may have the specialized knowledge you need. A land-locked forensic pathologist from the Midwest may not know much about SCUBA related accidents. A suburban forensic pathologist may autopsy a lot of car accidents, but not a lot of multiple gunshot wound homicides. Try to match the needs of your case to the experience of your expert. If it is a rare or unusual type of death, try to find an expert who has published on the subject. One way is to go to the National Library of Medicine (PubMed) and search the database for articles on the topic. Who is the primary author on most of the publications? Depending on the journal, many articles print the author's contact information in fine print at the beginning or the end of the article; and if the primary author doesn't do consulting, you can always ask them to recommend someone in their field of expertise who does.

7. Do they have experience testifying in cases such as yours?
Most forensic pathologists who practice in a City or County Coroner's office are very good at testifying in criminal cases, since they get a lot of on-the-job experience testifying for the District Attorney's office. But not all of them have frequent contact with Public Defenders or defense attorneys, so if you are a defense attorney, you want to make sure your expert has experience and understands the needs of the defense. Also, few practicing forensic pathologists have experience testifying in civil matters as a routine part of their job. The questions you may need them to answer may be beyond what their experience and training allows, or outside their "comfort zone" as an expert. For example, in an industrial accident, most forensic pathologists will be able to testify to the cause of death and the mechanism of death, but not all have the specialized knowledge regarding interpreting scene investigation to answer complex questions such as: What position was the person in when he was injured? Were the levels of drugs or medications they were taking capable of causing impairment? Make sure the pathologist has experience answering these types of questions before you hire them.

8. What is their expectation of their role?
Some pathologists see their role as very limited: you send them the material they need (typically medical records, police or incident reports, an autopsy report and microscopic slides) and they tell you what they think and write a report. Others will be more accommodating in offering you additional legal support: looking up references and articles, educating you and your staff about the medical issues as they come up, helping you understand the medicine so that you can formulate good questions for deposition or trial, and writing affidavits. If you ask, the individual expert will usually tell you up front what you can expect from them. You should also ask if they understand the different expectations of opinions written to comply with Frye versus Daubert rules of evidence. If an expert works in a Frye State and has never testified in Federal court, they may not be familiar with what Daubert standards are, and you will need to be more assertive in educating him or her about your jurisdiction's particular needs or legal quirks.

9. Do they teach?
This is a pretty good litmus test for communication skills. The most successful expert witnesses understand the complexity of their subject matter, but can find a way to simplify their terminology to make the subject accessible to a lay person. The average juror does not have an advanced educational level and is going to get lost unless the expert can speak to their level. Just because an expert has an academic appointment at a medical school or university does not mean they are good teachers. Just about any big-city Medical Examiner or Coroner's Office has academic affiliations because the local pathology residents are required to do a forensic pathology rotation. Does the practitioner have teaching awards? Do they teach groups other than doctors? If they do, then this is a pretty good indicator that they are comfortable with public speaking and can adjust their language appropriately for the audience.

10. How can you balance your needs with the pathologist's expertise, their proximity, availability and your budget?
Finding the right expert for your needs is a balancing act, and it requires you to be up-front with your expert about costs and expectations. The expert should have plenty of experience with similar cases to give you an estimate of how much time it takes him or her to review materials (for example: an inch of medical records usually takes an hour) or to research and write reports. A local expert with minimal experience may be sufficient if the case is a local one and you are on a tight budget; but you may need an internationally-renowned and published expert from far away if the case is a multi-million dollar class-action lawsuit. Obviously, the more famous or further away an expert is, the larger the expenses will be, and it is best to discuss these issues openly with your expert up-front so that there are no misunderstandings or scheduling complications as deadlines approach.

Sunday, October 26, 2014

Election Season: Vote for Coroner!


These are a couple of articles pertaining to coroners' races this Election Day that I have come across in the last week, the first from Indiana, and the second from Washington:


&

Why is the coroner an elected position? If you read the first article you would think that all a coroner does is go to schools and talk about drug overdoses to kids. In the second you learn that they have to help families with life insurance claims, and prepare evidence for prosecutors. Is this what a coroner's duties actually entail? 
No.

Well then. You may have to vote on November 2nd for your own county coroner. You want to know what coroners actually do, right? I work for one, and have performed more than 2,000 autopsies over the past 13 years as a board-certified forensic pathologist. Here is what I can tell you about elected coroners.
A coroner is a civil service management job, in charge of an office of the local government that oversees death investigation. When someone within the jurisdiction of that local government (usually a county) dies in a sudden, unexpected, or violent way, the coroner's office takes the call. Typically, the person answering the phone has to assess whether the case really should fall under the coroner's jurisdiction, and to decide whether a full death investigation or autopsy is warranted. Some coroners employ independent death investigators who go out to the scene of death and investigate the circumstances, looking for clues about medical history or foul play. Other offices rely on the police to do the on-scene death investigation. If an autopsy is warranted, then the coroner will hire a doctor to perform it. The doctor presents the autopsy results to the coroner, and the coroner decides, based on the autopsy report, what cause and manner of death to put on the death certificate. In order to be successful, a coroner needs—at a minimum—a good understanding of what generally kills people; enough medical training to know when autopsies are necessary; and the empathy and social skills to get along with the bereaved families, law enforcement, district attorneys, public defenders and the press.
How can voters assess whether the candidate for coroner is qualified to perform these duties?
Being a physician does not make you qualified to be a coroner. My ophthalmologist successfully manages a busy office and is a brilliant doctor, but she doesn't know anything about death investigation. I know several board-certified forensic pathologists who are fully qualified to perform autopsies and do death investigations, but have no management experience or training, and shouldn't be put in charge of a large bureaucracy. 

Being a coroner requires both of these skill sets combined: an understanding of death investigation, and office management skills. In many states, however, anyone can become coroner if he or she is over the age of 18, and prevails in an election to the position. 

So if you have to vote this November for a coroner in your county, I would suggest you look for the following characteristics:


  • Someone who understands what death investigation is and how it's conducted. 
  • Someone with medical background or training. 
  • Someone who wants to improve the office and bring in more funding and qualified staff—and does not brag about "doing less with more." 
  • Someone who understands the importance of American Board of Medicolegal Death Investigators (www.abmdi.org) certification for investigators; American Board of Pathology (www.abpath.org) certification for pathologists; and aims to get the office accredited by the National Association of Medical Examiners (www.thename.org) 
  • Someone who is unbiased and has experience working with grieving families and defense attorneys, as well as with law enforcement and the prosecutor's office. This becomes particularly important in high profile criminal cases, cases of officer-involved shootings or in-custody deaths. 
  • Someone who is a proven manager of an office with a staff on a similar budget, either as a small business owner or in government work.
Not all candidates will have these qualifications, and voting decisions can be difficult—but please educate yourself about the candidates, and do not fail to vote. Your vote matters quite a lot on the county level. You never get to know how much you need a competent county coroner until you suffer the unexpected death of a loved one. Few of us have this misfortune, but all of us should worry about who is in charge of the office that is charged with investigating the deaths of our families, friends, and neighbors.

Thursday, October 23, 2014

Forensic Sound Bites & Half-Truths

A reporter from the St. Louis Post-Dispatch called me earlier this week, saying she had Michael Brown's official autopsy report as prepared by the St. Louis County Medical Examiner, and asking me if I would examine and analyze it from the perspective of a forensic pathologist with no official involvement in the Ferguson, Missouri shooting death. I read the report, and spent half an hour on the phone with the reporter explaining Michael Brown's autopsy report line-by-line, and I told her not to quote me - but that I would send her quotes she could use in an e mail. The next morning, I found snippets of phrases from our conversation taken out of context in her article in the Post-Dispatch. These inaccurate and misleading quotes were picked up and disseminated by other journals, blogs, and websites. 
This is the text of my actual email exchange with Post-Dispatch health and medical news reporter Blythe Bernhard:

"From: "Dr. Judy Melinek" 
Date: October 21, 2014 at 5:53:21 PM PDT
To: Blythe Bernhard 
Subject: Re: media request

Great talking to you. Here are the quotes:

"The autopsy report shows that there are a minimum of 6 and maximum of 8 gunshot wounds to the body. The graze wound on the right thumb is oriented upwards, indicating that the tip of the thumb is toward the weapon. The hand wound has gunpowder particles on microscopic examination, which suggests that it is a close-range wound. That means that Mr. Brown's hand would have been close to the barrel of the gun. Given the investigative report which says that the officer's weapon discharged during a struggle in the officer's car, this wound to the right thumb likely occurred at that time. The chest wounds are  going front to back, indicating that Mr. Brown was facing the officer when he was shot in the torso, then collapsed or leaned forward exposing the top of his head. You can't say within reasonable certainty that his hands were up based on the autopsy findings alone. The back to front and upward trajectory of the right forearm wound could occur in multiple orientations and a trajectory reconstruction would need to be done using the witness statements, casings, height of the weapon and other evidence from the scene, which have yet to be released. The tissue fragment on the exterior of the officer's vehicle appears to be skin tissue, but only DNA analysis would confirm if it is from Mr. Brown or the officer. It is 'lightly pigmented' but even African-American skin can appear lightly pigmented on a small microscopic section, depending on what part of the body it came from."

This is how I was quoted in the Post-Dispatch the next day:

Dr. Judy Melinek, a forensic pathologist in San Francisco, said the autopsy “supports the fact that this guy is reaching for the gun, if he has gunpowder particulate material in the wound.” She added, “If he has his hand near the gun when it goes off, he’s going for the officer’s gun.”  Sources told the Post-Dispatch that Brown’s blood had been found on Wilson’s gun. Melinek also said the autopsy did not support witnesses who have claimed Brown was shot while running away from Wilson, or with his hands up.

Notice the difference? There's a big difference between "The hand wound has gunpowder particles on microscopic examination, which suggests that it is a close-range wound. That means that Mr. Brown's hand would have been close to the barrel of the gun" and "he's going for the gun." 
I was very fortunate to have the opportunity to correct this, in my own words last night, when Lawrence O’Donnell invited me to appear as a guest on MSNBC. Mr. O’Donnell allowed me to explain the autopsy findings clearly and in context—if not in full. The show is called “The Last Word,” and Lawrence O'Donnell makes sure he gets it. Despite the guest-badgering and interruptions that are a signature of his television persona, however, Mr. O’Donnell did allow me to correct the record that the St. Louis Post-Dispatch created. I am even more grateful to Trymaine Lee, whose companion article to last night's Last Word segment (linked above) serves as an excellent corrective to the Post-Dispatch article.
In my memoir of forensic training, Working Stiff, I quote my mentor, Dr. Charles Hirsch, as saying that “the best way to respond to a reporter is with your hat. Put it on and walk away.”
I don't agree. I believe the best way to respond to a reporter is to give the reporter accurate, succinct quotes, and set the record straight if they misrepresent what you said. 
Too many forensic pathologists are afraid of speaking out about their expertise, because they believe that all members of the press have a prepared agenda, or that professional reporters will misquote scientific experts to force a point that doesn't comport with the forensic evidence. But if we forensic pathologists all put on our hats and walk away, others who lack our medical training and experience will fill the void we leave. I want to make sure the reading and viewing (and tweeting) public have an opportunity to understand forensic science in the real world—what it can tell us, and what it can not. I'm not going to walk away. 

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