Sunday, August 12, 2012

Independent Forensic Assessments

Is there really such a thing? Recently, one of my consult reports was referred to in the news media as being "independent." It struck me as odd, because I had always been taught that a medical examiner's system was truly independent: independent of influence by law enforcement, and independent of the desires of a particular private interest (such as the family of the deceased or the insurance company), who may have a vested interest in the outcome of a death determination.

Yet in my professional experiences working as a consultant reviewing the work of countless coroners and medical examiners, I have been struck by how much their assessments rely on sometimes shoddy investigative work, limited resources in difficult economic times, and poor techniques or training. A good pathologist or coroner may reach the wrong conclusion on a case (e.g. mistake a homicide for an accident, or a suicide for a natural death) if the people at the scene of death hide or alter the evidence; if the police are anxious to "close the case" and fail to investigate certain leads preferring an easy answer; or if limited resources fail to provide an answer. One example would be limited toxicology screens designed to pick up only common drugs of abuse, which are used in many Coroner's offices nationwide. These tests will miss many antidepressants or antipsychotics, and will also miss many of the current designer drugs available on the street, and now over the internet.

So is a paid consultant's report truly independent? Clearly when I am being paid by an attorney or family member who questions the official assessment of a death they are paying me for my time and expertise: the hours of work it takes to review and investigate a case. I have also done and continue to do some pro-bono work, but I have been actually been told by attorneys, mind you, that that is considered more biased, as I can be perceived as a zealot when testifying. Ultimately, the question remains: does the fact that I am being retained by someone who might disagree with the official assessment, or has something to gain from a change in the death determination automatically make me biased?

I don't think so, because otherwise I wouldn't do it. I tell attorneys frequently that there may be a good chance I will agree with the original Coroner's assessment. Many times by hearing about the case over the phone and by knowing the reputation of the office or pathologist who did the autopsy I can tell a client with some confidence whether my conclusions will probably be able to help their case, or not. If not, they usually walk away, and sometimes find another expert who disagrees with me. But every once in a while even well-funded, accredited offices with pathologists who are well trained and honest make mistakes. And when they do I would hope they would afford my work the same degree of respect I afforded them: spend time reviewing it, see the bases for the opinions, and if they disagree, argue based on the facts of the case instead of attacking me personally.

Sadly, this has not always been my experience. I have had pathologists call me, incensed that I have disagreed with them, and start questioning other cases I have done, having spent their time investigating me instead of looking again at the conflicting facts in their own case. I have also been attacked in court for being a paid consultant, with insinuations made that I was looking for more money or for publicity. There is no logic to the attacks: I have nothing to gain by charging for and defending an indefensible opinion, in the process upsetting the family and attorneys, only for money or publicity. Publicity of a deficient opinion would damage my reputation and any chance of future consults. Yet, it is the nature of our adversarial system that encourages attorneys to trash the expert when they have no basis in attacking the expert's opinion. This is the way attorneys are trained and I expect that in court.

I do hold doctors to different standards. Getting to the truth of what happened, and doing justice to the facts presented by the body of evidence, should be our highest aspiration. And as experts we need to recognize that two highly trained and seasoned professionals can look at the same set of facts and come to different conclusions. This happens most frequently in the challenging, highly litigious cases that consultants review.

The reason is that the experts may be looking at the same facts, but interpreting the findings differently, based on differing professional experiences, and based on individual interpretation of articles in the medical literature. Who is right? Well, in our adversarial system, the expert who manages to explain it best to the jury or whose side wins the case is often seen as correct. But if we trust juries' determinations as arbiters of scientific truth, we would still be mistaken. There have been many well-publicized cases where juries have been swayed by junk science and innocent people have been convicted, even executed. (See: Innocence Project). Scientific accuracy needs to stand the test of time, be reproducible and falsifiable. And we need to accept the limits of science, that some things are just not knowable with the current state of scientific knowledge.

My lecture entitled "Medical Examiner’s Independence is Vital for the Health of the American Legal System" is scheduled for 9:05 PM on Monday October 8, 2012 at the next NAME (National Association of Medical Examiners) meeting in Baltimore. I will present the results of a recent survey of forensic pathologists and the recommendations of the ad-hoc committee on Medical Examiner Independence for a NAME position paper on the subject. I hope you can attend and participate in the discussion.

Thursday, June 7, 2012

Doctors & Cops Wear Sensible Shoes

It was on television the other night: the brunette detective had a sleek bob and she sauntered up to the dead body in 4 inch Louboutins. I don't actually know if they were Louboutins, but in novels and magazines Louboutins are the "Scotch tape" of cruel shoes. Does anyone remember Steve Martin's story about cruel shoes? We are now almost 30 years later and women are still strapping themselves into these stilts to accentuate their heels and narrow their instep, a modern equivalent of foot binding. My friend Leora has even written a book about it. - but I digress.

The point I am trying to make is while I expect inaccuracy in television when it comes to the nuances of forensic science (this particular episode had a sniper's rifle bullet that was removed intact with metal forceps - a double whammy!), I would expect costumers to know what the characters should look like. Have you ever seen a cop wear heels? I haven't. Ever. Even at the retirement party I attended a few months ago, both male and female cops wore sensible shoes.

Why? Because when you are a cop, or a forensic pathologist, you never know where your job may call you out to. I have had to navigate shifting docks at the marina, sandy beaches, blood-spattered gravel and cobblestones interspersed with bullet casings, and talus slopes where bodies were dumped, unceremoniously, from moving vehicles. It is hard enough to keep your balance in sneakers let alone fancy shoes.

So while I sometimes envy my friend and author Jenni Holm who boasts on her blog that she goes to work in slippers, I don't envy supermodels. My job is way more interesting anyway.

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.

Thursday, May 24, 2012

Medical Examiner Independence

This week the Supreme Court in Minnesota overturned the conviction of a 17 year old girl for the murder of her infant as a result of interference into expert witness testimony in her trial. The prosecutor was reprimanded by the State Bar for his conduct when he wrote a letter to the supervisor of a forensic expert stating that her involvement in defense work for a criminal case was a "conflict of interest." He has subsequently apologized.

I am glad to see the courts affirm that forensic science is objective and neutral and that its practitioners should be protected from influence and intimidation. Unfortunately, one overturned conviction in Minnesota is not going to correct a national structural crisis. In most cases, forensic scientists are not independent, but work for Sheriff Coroners: the same government entities that supervise law enforcement. Many forensic crime labs are under the auspices of police or prosecutors, and their employees are discouraged from sharing their expertise with defense counsel since they are considered "prosecution witnesses" and their reports are "testimonial," i.e. created to further prosecution. Many forensic scientists who train in institutions like these are not used to working with defense counsel and therefore their only contact with defense attorneys is when testifying, creating a clearly adversarial relationship. Although there are only about 500 forensic pathologists who are board certified practicing in the United States, many choose not to do defense work, and there have been several other cases, besides the Beecroft case, where experts who have done consult work for other counties or have come to opinions that were not politically popular were disciplined, restricted or retaliated against. We have a long way to go before we can correct the situation, and the first step would be for the major forensic and legal institutions and professional associations to step up and affirm that structural changes and policy changes have to occur on a national scale, as outlined in the recent NAS report on forensic sciences in the United States. Unfortunately, since law enforcement, death investigation and prosecutions are funded by each county, and local agencies are still trying to deal with the current economic downturn, I am not hopeful that there will be any significant changes occurring any time soon.

Sunday, May 20, 2012



My 12 year old friend is interested in forensic science. Can you recommend any books or sites that would be good for someone that age?

I would recommend "Forensic Science" by Alex Frith. I bought it for my son and he is 12. 

The DK Eyewitness book series is also spectacular:

Friday, May 4, 2012

Frequently Asked Questions

I sometimes get e-mail from high school and college students asking to interview me about what I do. Here are my answers to some of their frequently asked questions:

Q. Why did you decide to become a forensic pathologist?

A. I wanted to be a doctor ever since I was a kid. My dad was a doctor (a psychiatrist) and from him I was exposed to medicine as a career early in life. I spent a lot of time going through his anatomy textbooks and really wanted to know how the body worked. During medical school the Department of Pathology was responsible for training all the students in anatomy (the parts of the body), physiology (how those parts all work together) and pathology (what goes wrong in the body). The teachers were excellent and they encouraged me to go into pathology.

Q. What education do you need to become a forensic pathologist?

A. In order to be a forensic pathologist in the United States, you need to go to college, medical school and then do residency training in pathology (3 years minimum) and then fellowship training in forensics.

Q. What do you generally do each day?

A. When I get to work, in conjunction with my colleagues, I review the cases that were brought into the office over the previous 24 hours, and I decide which cases I will autopsy. I typically do one or two autopsies a day. After the morning review, I go into the morgue and perform the autopsies. Each one typically take me 45 minutes to an hour. It takes longer if the case is complex, like a homicide. In the afternoon I type up my autopsy reports, call the families of the deceased and let them know what I found, and that is usually when I am scheduled to testify in court.

Q. What is the most memorable experience you've had as a forensic pathologist?

A. September 11, 2001. I was one of the doctors in New York who recovered the remains of the people who died in the World Trade Center attack. It was an overwhelming experience, and certainly the most memorable; it will be part of who I am for the rest of my life.

Q. About how much on average does a forensic pathologist get paid per year?

A. Salaries vary based on location and experience but they range between $120,000 and $300,000 a year.

Q. Has the technology or methodology changed since you began working as forensic pathologist?

A. Not by much. Most of what we do in an autopsy room is no different from what was done, technically, for hundreds of years. What has changed is the complexity of the science: the radiology technology is a lot more advanced and the breadth of knowledge one needs in order to assess all the different kinds of ways people die has most certainly expanded. There have also been advances in clinical chemistry, toxicology and molecular biology that affect the tests we rely on the diagnose diseases, poisonings and to identify individuals (i.e. through DNA).

Q. What most surprised you about forensic pathology?

A. That I would get used to the smell, not even mind it at all over time.

Q. Is there anything you know now that you wish you had known when you began working as forensic pathologist?

A. I wish I knew how political it could be. Not that it would have changed my choice, but it would have prepared me for many of the stresses that stem from dealing with the demands of governmental cost-cutting measures and the political pressure when dealing with high-profile cases.

Q. What do you like most about being a forensic pathologist?

A. Helping families with their grief and explaining to them what happened to their loved one. I find it gives them the closure they need and sometimes I am the only one who has taken the time to explain the medicine to them in a way they understand, even following their loved one's long hospitalization. I also like testifying in court and seeing the eyes of the jury light up when I explain what happened and they "get it." I also really like teaching students for the same reasons. A jury needs to understand the scientific basis for my opinions in order to render a just decision, so it gives me a lot of professional satisfaction to be able to play that important role in the legal system, whether it be to testify on behalf of the prosecution or the defense.

Q. Is there a lot of work in your field?

A. There are many job openings for forensic pathologists. According to the National Association of Medical Examiners there are only about 500 board certified FPs practicing forensic medicine in the U.S. We need about twice that. That is why many forensic autopsies are done by hospital pathologists lacking the specialized forensic training that I have.

Q. How many autopsies do you perform?

A. I have performed over 2,000 autopsies and I have been in practice nearly 10 years. I average 200-250 cases a year. On a typical day I do 1 or 2.

Q. How long does it take you to start performing autopsies after being certified?

You do autopsies as part of your training in medical school and residency. You need to do 50 autopsies as a resident (a pathologist in training) in order to be allowed to sit for the Board Examinations, so that's before you are even board-certified.

Q. What schools did you attend? How long have you worked in this field?

A. My resume is on my website and it documents my schooling and professional accomplishments. See

Q. What was your major in college? What major would you recommend for someone interested in forensics?

A. I majored in biology in college. I didn't know I wanted to be a forensic pathologist until I did the required rotation throught the medical examiner's office in my residency in pathology. I would recommend majoring in any field you love but making sure you take the prerequisite courses for medical school admission. Depending on the college you attend, you can sometimes be a "pre-med" major, though in many cases students interested in medical school major in the sciences, like biology or biochemistry.

Q. What would you say was the hardest obstacle while heading towards your major?

A. I found that applying to medical school was a "numbers game" and it didn't matter where I had gone to college or that I had done all these extra-curricular activities (like theater, or working in a lab). On applying to medical school all they wanted to know was my GPA and MCAT scores. If I didn't hit the magic cut-off, I didn't get an interview. My best advice to you if you are pre-med is to take easy courses where you can get straight A's and take practice courses for the MCATs so you score high. I found medical school a bit boring too: lots of memorizing. It got a lot more interesting in 3rd and 4th year when you finally got to see patients and behave like a doctor.

Q. How were you able to pay the cost of schooling?

A. Paying for college and medical school in the United States is very expensive. My father passed away when I was a teenager, and had left me a modest inheritance. That was just enough to pay for (private) college and (state) medical school. Most of my friends and colleagues took out a lot of student loans to pay for medical school. May of them are still paying off the debt.

Q. Are you happy with your career choice? Is the reward worth the work you do?

A. Absolutely!

Q. What do you think you would be doing if you weren't doing this?

A. Either teaching medicine or writing or both. Actually, I am already teaching and writing as well.

Thursday, April 26, 2012

Doctor and Patient: Reinventing Year Three of Medical School

A recent article by Pauline Chen, MD in the New York Times discusses changes in the medical studies curriculum which are meant to ensure that medical students retain their empathy. Unfortunately the process can and will become undermined by a vicious residency training system. I found that it wasn't medical school that made me cynical. It was a general surgical residency where I was working every other night on call, over 120 hours a week. Didn't know there were 120 hours in a week? Well, I didn't either until I did the math. This translates into up at 5 am, at the hospital from 6 am, then overnight until the next evening at 10 pm, then home for a few hours of shut-eye before you repeat. No wonder I quit my surgical residency after only 6 months!

During that time I was distressed at how I was expected, even encouraged, to continue to care for patients despite overwhelming exhaustion. When I collapsed from the stress I was told that this was somehow my problem, and not the result of my grueling schedule. When I went to a therapist, the situation was normalized and I was prescribed Paxil to deal with my depression and anxiety, when I should have been told to leave. The entire medical education system, I soon realized, was set up to get the most amount of labor from the youngest, and financial incentives existed to maintain the status quo. Residents are essentially an itinerant work force: residents are only trainees from between 3 to 7 years and then they move on. Unionization is nonexistent, or discouraged, and most trainees feel that putting up with the crazy hours is the way to pay their dues and the payoff will come later, in the salaries and perks that come with being an attending surgeon.

I genuinely don't think the system will ever change unless there is some pressure from the outside (i.e. federal regulation) to reform it. The doctors and hospitals who currently benefit from the cheap labor of residents in teaching hospitals have no incentive to change it and the residents are powerless to.

While I admire those educators at Harvard who are willing to invest in improving medical school experiences for their third-year students, they really need to take a look at their own backyard first and first examine their residency training programs. Start with Harvard. That was the where the surgery program I quit 10 years ago was. I wonder if it has changed...

Wednesday, April 18, 2012

Frontline: The Real CSI

Frontline: The Real CSI

Last night I watched the most recent installment from PBS and ProPublica about forensic science in the United States. "The Real CSI" focused primarily on fingerprint analysis and bite mark analysis, two forensic methodologies that have been criticized recently by the Federal National Academy of Sciences (NAS) report for a lack of scientific rigor. The show's producers interviewed several prominent judges, and forensic specialists, including pathologist Dr. Cyril Wecht, about the issues of credentialing and on-line diploma mills. Their journalism student even got a quickie credential for $600 from an on line organization called ACFEI. What they forgot to mention were the credentials recently obtained by Steve Eichel, Ph. D., a forensic psychologist, for his cat.

Further missing from the discussion was the existence of a credible non-profit credentialing organizations within the field of medicine: the American Board of Medical Specialties (ABMS) and the Accreditation Council for Graduate Medical Education (ACGME). The former sponsors examinations created by leading experts in the field with published failure rates (about 33% for forensic pathology) and the latter accredits and inspects hospitals including residency and fellowship training programs. In order to become a board-certified forensic pathologist I went through 5 years training at an ACGME-certified residency program, 2 years at an ACGME-certified fellowship program, and I had to sit for 3 tests. The first two (anatomic and clinical pathology), taken together over a two-day period, required me to study for nearly a year. For the final subspecialty test in forensic pathology, I studied for over a month, but by then I was also performing forensic examinations on a daily basis under direct supervision. Both were mind-numbing exercises in minutiae and I am not certain they make me a "better" forensic pathologist, but the amount of work necessary in order to pass does set a baseline for motivation and intelligence, if not competence. Clearly, in my career since then I have seen board-certified forensic pathologists make errors, and I am not immune to errors myself. But it is the egregious errors of un-boarded practitioners that tend to cause the most problems. See: Dr. Steven Hayne in Mississippi and Dr. Charles Smith in Canada.

While it would be reasonable to pass laws that require forensic pathologists to be board-certified by the ABMS in order to testify as experts, it would immediately cause chaos in our courts since there are insufficient numbers of forensic pathologists to cover the needs of the United States. The National Association of Medical Examiners (NAME) estimates that there are approximately 400 board-certified forensic pathologists practicing in the U.S., less than half of what is needed to perform all the forensic autopsies needed. We need to increase the numbers of forensic pathologists by encouraging doctors to go into the field, in the same way we currently encourage doctors to go into primary practice in high-need areas: with outreach in medical school and loan-forgiveness programs for those entering the field.

Furthermore, attorneys need to start challenging experts more about their credentials and qualifications. Attorneys need to know how to find a qualified expert in forensic pathology, and I am hopeful the Frontline series will educate them.