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You Can Die In the Wrong Place

If, and it is, the medicolegal death investigation system is important to public health, the criminal justice system and last but np means, least families of their deceased loved ones, why is the medicolegal death investigation system in this country described as a frayed patchwork of medical examiners, coroners on hybrids of the two. 21 states have medical examiner systems, 11 have coroner systems and 18 have hybrids. A system implies completeness, working together and uniformity. The medicolegal death investigation system in the United States exhibit neither completeness, working together nor uniformity. Regardless of the “” system “, 50% of the population find themselves under the corner system and 50% on the medical examiners system. At this point in this introductory episode, we should pause to make sure that we understand what we’re talking about when we say a “coroner “and a “medical examiner. The coroner is a carryover from the old English system wherein a crowner was involved in investigating the death of subjects to protect the interests of the Crown. The sheriffs had the responsibility but was suspected of not being totally truthful, so a crowner was installed to watch over the sheriff or replace him .Coroners in our system are usually elected officials, they are usually not physicians, the requirements to become a coroner may be minimal, the coroner usually must rely upon the help of a pathologist to perform autopsies and coroners usually have other jobs that take priority in their lives. The requirements to become a coroner differ from state to state. It was once described that to serve as a coroner in Georgia the individual must be a registered voter, at least 25 years of age, no felony conviction, high school diploma or equivalent ,an attestation to the above a via affidavit and an annual training period of one week. Medical examiners on the other hand are almost always physicians, they are appointed rather than elected or, they usually pathologist and they are most often forensic pathologist. The terminology is unique and so confusing that an untrained individual would need a scorecard to identify the players. For example. Coroners are appointed and not elected in Hawaii, Kansas, and North Dakota. Coroners are physicians (not necessarily medical examiners) in Kansas, North Dakota, Louisiana, and Ohio. Coroners are sheriffs in some parts of California. They are prosecutors in Nebraska and some part of Washington state. They are elected 2 per county in New York and they are known as Justice of the peace and Texas. I was personally miffed when a seasoned journalist in Texas referred to me as “the coroner “; As mentioned above we do not have corners in Texas. In addition, my education, training, and experience consist of four years of college; four years of medical school, one year of internship, four years of anatomic and Clinical pathology residency training and a year of fellowship training in forensic pathology. The confusion in our terminology is not limited to coroners; there are medical examiners variations and confusion as well: In some states, a physician, not necessarily a pathologist, who assists in death investigation or functions like a coroner is called a medical examiner, Michigan. In some states the medical examiner it is not necessarily a physician, Vermont, West Virginia, and Wisconsin are examples. In addition, some people who do insurance physical examinations or job-related physical examinations are also referred to as “medical examiners”. Once again, depending on the state you need a scorecard to identify the medical examiner. You would have to be familiar with state law. Ideally, a “medical examiner” would be a forensic pathologist. Looking at the facilitates where the medical examiner works, 465 facilities perform forensic autopsies in this country. In 2004, the Last year for which I could find data, only 40 of 465 offices were accredited by the national Association of medical examiners, the applicable accreditation body. This body establishes minimal criteria by which the office should function to apply for and be inspected to become accredited. I would like to emphasize that this body establishes minimal criteria for accreditation.

The small number of offices accredited in the United States begs the question, why? The truth is that some officers cannot qualify, many offices cannot meet inspection and accreditation standards, and then in some offices the caseload is too high. The national Association of medical examiners will not a credit an office wherein any one medical examiner doing more than 250 autopsies per year. The thinking, when one exceeds 250 autopsies per year it is not if but when the mistakes will occur. Doing the opioid overdose death crisis it was alleged that some offices were willing to give up their accreditation so that they could have the medical examiners perform more than the 250 autopsies per year in order to keep up with the workload. The opioid deaths crisis was followed by the COVID-19 pandemic. It is probably not healthy to walk around contemplating your mortality but the average person in the street in Houston Texas do not know where the medical examiner’s office or the morgue as they call it, is located. They have no idea about the procedure and the fact that an autopsy is just part of a complete postmortem examination. The complete postmortem examination consists of three parts: the crime scene investigation, the autopsy, and the involvement by the Crime lab. DNA analysis and toxicology, either or both, is an especially important factor in many autopsy cases. The turnaround time varies from one lab to the next and these results are of utmost importance in completing the postmortem examination and the wait can be up to 90 days in some of the best ran labs. The average citizen does not know whether they are in a coroner, medical examiners are hybrid system. and the systems are not all the same. In some instances, it matters where you die. I have attempted to define the coroner and now I would like to segue back and defined forensic pathology. Forensic is a public forum, involving the courtroom and can be a debate/argument. Pathology is the study of the nature and causes of diseases. Forensic pathology is the study of disease and injury that is of interest to the public, public health, and courts. There have been talks and discussion forums on the need to change the coroners system to a complete medical examiners system that date back to 1928 with follow up meeting by different groups in the years 1932, 1954, 1968, 1985, 2003. The latest effort was by the national Academy of science in 2009. Somehow it all seems to come back to economics; the county coroner has a budget, and it is well known that the entire system is underfunded. If the funds are short near the end of the month or the budget cycle, the coroner may have to decide as to which death, he have funds to get autopsied. On the other hand, it is a long, arduous, and expensive trip to obtain a medical education and become a forensic pathologist. In the year 2019-2020 the average cost of public medical education for in-state students was $37,556 per year and $61,858 per year for out-of-state students. Forensic pathologists are among the lowest paid of the physician groups. And in addition, it have to be a labor of love and I’m not totally sure that throwing more money at it will increase the number of pathology residents who choose to study forensic pathology in a fellowship program.

The medicolegal death investigation system impacts our personal liberty and freedom, financial well-being, injury prevention and control, mortality analyses and the assessment of medical care.

The real world of forensic science is quite different from televised CSI. We called it a medical examiner’s system but if there are 3171 counties in the United States And only 960 or 31% of those are covered by a medical examiners system, I submit that we have a coroner system by democratic rule. In addition, there is approximately 500 board-certified forensic pathologists working full-time within the system and approximately 1900 corners, once again, you would not have to be a mathematician to conclude that we are, according to the numbers, a coroner system. It may sound pleasing and comforting to say that we have a medical examiner’s system, but the fact is we do not. The coroner is an elected, non-physician in most instances, and an official who is on the front line of deciding whether your loved one death warrant further investigation by the medical examiner. If the corner decides for whatever reason that your loved one does not fit the criteria, or the budget, he and he alone decides that no further studies or autopsy is required. When I was in Georgia, on call for autopsy of the following day, the medical examiner investigator called me to inform me that the coroner wanted to send in a case for autopsy and would like my opinion. I instructed her to tell him to call me as I would like to discuss the death scene with him. The investigator called back to inform me that the coroner said that he had not gone to the death scene. I instructed her to tell him that when he returned from death scene to please call again. May be an isolated example and I certainly hope so. Because there are lots of good coroners out there that have done a good job and have done a good job over the years. It does not excuse the fact that there is much room for improvement. The fact is the coroner system is here to stay and at best we can work on improving it. I mentioned earlier and will segue back to later that of the 4 million graduates in this country each year, 43% find themselves either unemployed or underemployed. Approximately 70% of criminal justice majors find themselves in the underemployed or unemployed category. There are 3171 counties in the United States, as previously mentioned, each has a county Coroner and in New York they have two per county. In addition, each office has at least one deputy corner. It seems to me that criminal justice majors who are underemployed or unemployed maybe a perfect match for the system. Each office could start off by bringing one of these young people in as a deputy and grooming them to eventually take over the office as a coroner. One of my tenents in life is that very few people come up with original ideas. Therefore, I believe that this is not a new idea and I cannot help but wonder why it is not been discussed. Could it be that we were so intent and shortsighted on getting rid of the coroner system that we are unable or unwilling to look at improving upon it in the interim. When those in leadership roles say that we have about 400 to 500 board-certified forensic pathologist that are currently practicing full-time and the national need is approximately 1000 full-time practice in board-certified pathologist. That would still have to be a mix system with more coroners than medical examiners. We as forensic pathologist cannot keep up with the current allocated positions in the nation. About 10% of the positions in the nation are currently vacant. Will never close the gap by training more forensic pathologist because pathology residents are simply not answering the calls. For example, in years past out of 15,000 new medical student graduates, 5000 would seek postgraduate training in internal medicine, 1000 would seek training as radiology residents, 500 would seek training in general pathology and 40 would choose forensic pathology training. The number just don’t add up, If the rate of entry of new board-certified, full-time, practicing forensic remains the sane and we need 1100 to 1200 instead of the 500 we currently have, we cannot get there from here!


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