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4 INFRASTRUCTURE AND TRAINING INFRASTRUCTURE OF THE MEDICAL EXAMINER SYSTEM Victor Weedn In 2001, NAME conducted an infrastructure study of medical examiner and coroner facilities. In the absence of a nationwide list of those offices, the survey was sent only to individual members of NAME (primarily medical examiners but also some coroners). Some 125 jurisdictions, covering 39 states, replied. The jurisdictions covered a total of 175,000 deaths and 90,000 autopsies per year. The survey dealt with funding, workload, staffing, services, and facilities. Overall, the survey revealed that systems were small, poorly funded, and housed in outdated facilities. There was wide variation in funding, ranging from $30,000 to $16 million per office. The average expenditure was $1-2 million, which translates to $1-2 per capita. Most offices spent $2,000-3,000 per autopsy. Accredited offices spent more per capita than did nonaccredited offices. Findings on workload revealed even greater variation. The number of autopsies performed each year, on a per capita basis, varied by a factor of about 40. The average office performed 707 autopsies per year. More than half the offices were doing more than the NAME-
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recommended standard of 250 autopsies per pathologist. By that measure, most jurisdictions have heavy workloads. NAME bars accreditation if a pathologist performs more than 350 autopsies per year. The number of pathologists per office varied from one to 24, and 10% of the medical examiner slots were vacant. Of the 379 pathologists who replied, 80% were board-certified, but the questionnaire neglected to ask whether they were board-certified in anatomic pathology or in forensic pathology. Offices averaged 6.4 death investigators (range, 1- 44). Death investigators work with medical examiners and coroners to obtain and document information on reported deaths, conduct scene investigations, and participate in other parts of death investigations as directed by medical examiners or coroners. The overwhelming majority of offices had body transport and radiology. Only 37% had in-house toxicology laboratories, and 14% in-house crime laboratories or DNA testing. Spending for toxicology was inadequate: an annual average expenditure of $50,000, including salaries. Many medical examiner facilities were a half-century old, but the average facility was 20 years old; many had inadequate space. Quality indicators revealed deficiencies. Although 83% had mass fatality plans, only 38% had bioterrorism plans. Slightly less than half of jurisdictions (43%) had both in-house toxicology facilities and death investigators; nonaccredited offices were far less likely than accredited offices to meet this quality measure. Medical examiner and coroner systems need more funding to enhance quality with greater staffing, lower workloads, and modernized facilities. Training and Certification in Forensic Pathology Ross E. Zumwalt Training programs in forensic pathology are monitored by the Accreditation Council for Graduate Medical Education (ACGME), which confers accreditation on the residency program. ACGME carries out its function through residency review committees, one of which is devoted to pathology. The pathology residency review
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committee covers not only forensic pathology programs, but all general pathology and other subspecialty programs. There are 41 forensic pathology training programs with full accreditation and three applications for new programs. The 41 programs sponsor a total of approximately 76 positions; thus, most carry fewer than 2 positions. Most programs are in the coroner or medical examiner office rather than under the institutional umbrella of a medical school. Among the core competencies required of trainees for accreditation is performance of at least 200 but not more than 300 autopsies per year. Those figures are lower than the former requirement of at least 250 but not more than 350 because of the increased complexity of cases and the greater number of tests to interpret. Manpower is a major concern. Since 1959, about 1,150 certificates have been awarded. In 2002, 34 forensic pathologists were newly certified. The failure rate on the American Board of Pathology examination in forensic pathology has been about 38% but this rate represents a disproportionate number of failures of candidates qualifying for the exam by experience rather than by formal fellowship training. Recent changes requiring all candidates for examination to have formal accredited training are expected to increase the pass rate while ensuring quality. A greater pass rate, however, cannot fulfill the demand for sufficient board certified forensic pathologists for all medicolegal autopsies in the United States. More training programs and more trainees are needed. Training, Registry, and Certification of Death Investigators Mary Fran Ernst The origin of lay examiners who work for medical examiners traces back to the 1950s. In the last half-century, greater training opportunities have emerged, but they remain jeopardized by scant funding. The first formal 1-week training course was offered in 1974 by St. Louis University. Seven states now mandate minimal training requirements for death investigators. The basic week-long course for death investigators includes death-scene investigation, examination of the decedent at the scene,
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estimation of time of death, evidence recognition, notification of next of kin, legal issues, mass-casualty instant response, organ and tissue donation, and testifying in court. There are lectures on the ancillary forensic sciences, such as anthropology, odontology, toxicology, archeology, and forensic psychiatry. Credentialing of individual death investigators has improved over time. Death investigators can now be recognized as affiliate members of NAME or members of the American Academy of Forensic Sciences (AAFS), a society of diverse professionals dedicated to the application of science to the law. In 1995, NIJ organized the first technical working group to develop national guidelines for scene investigation by death investigators. The guidelines, which were released in 1998, specify 29 essential components of a thorough death scene investigation. Also in 1998, the American Board of Medicolegal Death Investigators was created to certify death investigators. It confers two levels of certificationregistry and board certificationand recertifies people every 5 years. The goals of certification are to identify professionally qualified death investigators and to assist the courts and public in assessing their competence. A key threat facing the profession is the overall shortfalls in state budgets. Training funds have been most adversely affected and in some cases eliminated. Research Issues Kurt Nolte The field of medicolegal death investigations is strikingly limited in its research capacity. Only 11% of the nation's 125 medical schools have full-time faculty members who are forensic pathologists—39 total faculty members. Only two are principal investigators on research grants, one other forensic pathologist has some degree of research funding (co-investigator), and the field’s research potential is curtailed by a shortage of future researchers. Only 38% of forensic pathology training programs offer any research opportunities to trainees. In 2002, there were 113 scientific reports in the field’s two forensic pathology journals. The vast majority were descriptive studies
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in the form of case reports or case series. Only 31 (27%) were experimental (hypothesis-driven) studies. Of the latter, less than one-third (29%) had received funding, mostly from foreign sources. Of the five funded by US sources, none had a forensic pathologist as principal investigator. Over a 3-year period, 1993-1996, Morbidity and Mortality Weekly Report (MMWR) included 48 articles to which a medical examiner or coroner contributed (Hanzlick and Parrish, 1998). The most frequently cited reasons for lack of research commitment were time constraints, lack of academic institutional support for research in forensic pathology, and isolation from academic institutions. Other reasons were regulations covering confidentiality, poorly standardized data acquisition and information technology, and lack of federal research support. A small amount of research funding is available from several agencies: the Centers for Disease Control and Prevention (CDC), NIJ, AAFS, and the National Institutes of Health (NIH). The latter has the largest commitment, totaling six studies, but none has a forensic pathologist as principal investigator. Despite the low level of research support, there is an abundance of research opportunities in forensic pathology, largely through collaborations with other fields: epidemiology and surveillance of violent deaths, substance abuse, unintentional injuries, environmental hazards, and infectious diseases. Forensic pathology researchers can also play a key role in research on public health interventions, trauma care, pharmacogenomics, and pathogenesis. Forensic pathology has a treasure trove of research assets including population based epidemiologic data, a window on unnatural deaths, and the only remaining significant source of autopsy tissues. None of the field’s research opportunities can be realized, nor can the evidence base of the field grow, without greater funding from federal research institutions. Toxicology Issues Alan Trachtenberg One prime example of the role of death investigations in epidemiology and public health policy is in the arena of substance abuse. Death investigations have been an essential resource for shedding light on a dramatic rise in opioid-overdose deaths during a
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10-year period (1985-1995). Epidemiology researchers found that the poisoning death rate in men 35-54 years old nearly doubled in that period, and the drug-related poisoning rate nearly tripled in the same group. About three-fourths of those deaths were caused by drug overdoses (Fingerhut and Cox, 1998). The reasons behind the trend were not well understood, so researchers set out to obtain fuller accounts of the drugs or combination of drugs used in the overdose deaths. What was required was a re-examination and subclassification of more than 1,000 drug-related deaths. The Substance Abuse and Mental Health Services Administration (SAMHSA—the government agency responsible for surveillance of drug-abuse trends, funding of treatment services, and regulation of methadone clinics serving 200,000 patients in more than 1,000 programs nationwide—wished to understand the trend in substance abuse deaths so that it could shape regulatory policy. The surge in drug-related deaths in one state, North Carolina, was probed through research collaborations with the CDC. The research uncovered that the source of methadone at the death scene identified by the medical examiner was a tablet form of methadone used in pain treatment. The tablet form turned out not to be the same as the type of methadone used in drug-treatment programs. That suggested that the methadone was not being diverted from the state’s treatment programs regulated by SAMHSA. SAMHSA and other government agencies could thus focus their prevention and control efforts on the illicit market, which was the source of the methadone tablets. The epidemiologic research and medical examiner involvement in this case was key to defining the nature of the problem and to public health policy. Epidemiologic research using death scene investigations has also been critical in other states and has pointed to a problem with multiple drug use, as distinct from use of single agents (Cone et al., 2003). Discussion Discussants voiced their views on the following: Insufficient resources. Not enough resources are devoted to the field of medicolegal death investigations. Cutbacks in state and local funding have led to elimination of essential ancillary
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services, such as toxicologic testing in traffic-related deaths.(Victor Weedn, Alan Trachtenberg). Lack of competitive salaries. Salaries are low, and so impair recruitment and retention of forensic pathologists (Richard Bonnie, Randy Hanzlick, Ross Zumwalt, Victor Weedn). Lack of modernized equipment and poor working conditions. These hamper the field and its development (Victor Weedn). Lack of research. Researchers frequently use medical examiners’ data without including the medical examiners as collaborators (Randy Hanzlick). Lack of research stymies public health and precludes development of an evidence base for the field itself (Richard Bonnie, Randy Hanzlick). Opportunities for growth. The field has a genuine opportunity for growth because of burgeoning interest by the public health and criminal justice communities. Public health had ignored forensic pathology for years until it began to focus on violence as a public health issue. The time is ripe for greater collaboration with public health and criminal justice, as long as the field expands its manpower through an infusion of funding and trainees (Marcella Fiero, Alan Trachtenberg). New forms of financing. User fees are used in some jurisdictions for select purposes, but they often have idiosyncratic purposes and so fail to promote standardization and comprehensiveness in data acquisition (Victor Weedn). A piecemeal approach to disease or injury however, is not a good way to garner resources (Kurt Nolte). New forms of financing need to be cultivated for the field (Richard Bonnie). Commitment to the field. Greater efforts are needed to interest first- and second-year medical students in forensic pathology before they begin to commit to other specialties (Mary Fran Ernst, Kurt Nolte). Forensic nurses could be used to assist medical examiners and coroners in handling the increasing public interest in addressing nursing home deaths (Vincent Di Maio)
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