Sunday, June 3, 2012

Do It Right the First Time

Solano County recently reported that despite concerns about the quality of work performed by a previous unqualified forensic pathologist, Dr. Thomas Gill, they are not going to pay for a complete review of his work. Dr. Omalu, a Board-Certified Forensic Pathologist from San Joaquin County was hired to review 32 of Gill's closed cases and found that Dr. Gill's conclusions on eight of the deaths were "unreasonable" and more than half had "critical errors." The decision to not reassess the rest of his work on over 300 cases is cause for alarm. It appears that the primary reason is cost ("lack of resources"), since there was no evidence that a crime had been committed in the other cases. Yet the mission of a Coroner's Office is the accurate determination of the cause and manner of death in all cases, not just in ones where foul play is suspected. An incorrect death determination means that an accidental death may be called natural, or worse, undetermined. That may not seem like a big deal, but for a family that has been denied payment on an accidental death insurance policy it is a huge deal. But when an agency's financial savings take precedence over quality of work, then as the saying goes, you gets what you pay for. I am sure Solano saved a lot of money by not hiring a Board-Certified Forensic Pathologist in the first place, except now they are paying for it in bad publicity and in the cost of reviewing his work.

Whether a system is set up as a Medical Examiner or a Coroner System it is imperative that they operate with integrity, independence and work to attain the highest standards of practice. Accreditation by the National Association of Medical Examiners would be a good first step. Unfortunately this is not a requirement in any State nor is it a requirement by any federal standards. Why is it that if someone dies in a hospital there is State law that requires that their death certificate be signed by a licensed physician; yet if someone dies in a sudden, violent or unexpected way the death in California can be certified by a Deputy Coroner qualified by a 2 week course in death investigation? Typically, the Coroner will rely on the autopsy report generated by a pathologist (assuming they ask for an autopsy) but the pathologist does not need to be board certified, so their forensic training may only consist of a one month rotation in residency! Most pathologists have years of training in surgical pathology and have to pass their board certification in order to practice in a hospital, but have very little exposure to forensics in their training. Yet most Coroners don't see a problem with hiring a hospital pathologist to perform a forensic autopsy. That would be like going to a general surgeon to perform brain surgery. Personally, I would trust my brain only to a Board-Certified Neurosurgeon.

While I would like to see more laws requiring board certification for forensic pathologists, I am skeptical that this kind of mandate is not going to be supported by local Coroners, since that will drive up their costs. Plus, there are currently too few Board Certified Forensic Pathologists to perform all the forensic autopsies in the U.S. So what can we do to improve the situation? Two suggestions are:
1 - Federal Standards that come hand in hand with funding to any State that improves its death investigation and certification system and hires Board-Certified Pathologists
2 - Outreach to doctors in medical school to promote forensics by our core professional organizations, NAME and AAFS
Can you come up with any others? Please comment below.