Perspective: Pathologists' Assistants Can Alleviate Burdens on Forensic Pathologists

Alyse Gray

January 31, 2022

The United States is experiencing a shortage of medical examiners. Like everything else, this ongoing problem has only been exacerbated by the COVID-19 pandemic. Prior to the pandemic, the opioid crisis caused a huge uptick in deaths nationwide. In October 2017, Brian Peterson, MD, then president of the National Association of Medical Examiners, told The New York Times , "The crisis has led to staff burnout, budgetary problems, and threats to accreditation since many offices have to perform more autopsies than allowed by industry standards."

As time went on, things didn't improve. On February 25, 2020, another New York Times article, "Piled Bodies, Overflowing Morgues: Inside America's Autopsy Crisis," reiterated . Peterson's concerns, this time providing a visceral look into America's crowded morgues, noting that few solutions to this problem have been offered.

But this was before the COVID-19 pandemic. Bodies are now piling up in refrigerated trucks and are being stored on ice rinks. The case burden on forensic pathologists has reached a breaking point. Clearly, additional highly trained forensic pathologists are needed, but there are no solutions in sight.

In other areas of healthcare, physician extenders, such as nurse practitioners and physician assistants, are utilized to meet growing demands. But what do overworked pathologists do? Enter the pathologists' assistant, an obscure, mid-level, lab-dwelling provider specializing in dissection.

Pathologists' assistants possess graduate-level training equivalent to that of physician associates. Like other medical professionals, they are required to pass a certification exam and maintain their credentials through continuing education. Forensic autopsy pathology training is a standard part of the curriculum in pathologists' assistant programs, as are clinical rotations at a medical examiner's or coroner's office.

Under the supervision of a pathologist, pathologists' assistants can perform surgical and autopsy specimen dissection, report preparation, and everything else leading up to the final diagnosis. Pathologists who utilize pathologists' assistants can spend more time at the microscope making diagnoses, which improves the overall turnaround time and efficiency of their practice. Pathologists' assistants are also responsible for teaching residents and trainees in nearly every academic medical center in the country. In a hospital autopsy setting, pathologists' assistants perform the external exam of the body and the prosection of organs, select tissue samples for microscopy, and prepare the autopsy report.

Pathologist supervision typically involves a review of the external exam and internal findings. Later, the pathologist looks at the slides and reviews the patient's medical record to make the diagnosis and determine the cause of death. Depending on complexity, a hospital autopsy can take anywhere from 2–5 hours. The length of a forensic autopsy from start to finish is similar but can take more or less time, based on the circumstances of death. Reviewing a pathologists' assistant's findings takes about 20–30 minutes. This ultimately saves the pathologist hours of work.

While most pathologists' assistants work in a hospital or lab setting, they've been integrated into a few medical examiners and coroner's offices in the United States. The Wayne County Medical Examiner's Office in Detroit was the first office in the country to do so. By employing three pathologists' assistants (whose combined salaries are likely equivalent to the salary of a single senior medical examiner), the office successfully reduced caseloads and enhanced their training program. Recently, the state of Arizona followed suit, as did the DeKalb County Medical Examiner's Office in the suburbs of Atlanta, Georgia.

While more offices are jumping on board, there still are very few pathologists' assistants working in medical examiner's and coroner's offices. It's partly a matter of education. Some forensic pathologists aren't even aware of the profession's existence, since it's relatively new — the first pathologists' assistant training program was established in 1969. The American Society of Clinical Pathology, the accrediting body for pathologists and laboratory professionals, didn't provide official certification for pathologists' assistants until 2005.

Today there are 15 pathologists' assistant training programs in the United States and Canada and 2844 certified pathologists' assistants in practice. In comparison, the US has only about 500 forensic pathologists, and this severe shortage is unlikely to be remedied any time soon. While there is a growing interest in forensic pathology among young people, the road to becoming a forensic pathologist is extremely rigorous, time consuming, and expensive, plus forensic pathology is one of the lowest paid physician specialties in the country. According to a 2014 study, the mean salary for chief medical examiners was $219,778, for deputy chief medical examiners it was $192,872, and for other medical examiners it was $183,597. In comparison, the Medscape Pathologist Compensation Report 2015 found that the mean salary for all pathologists was $267,000.

Meanwhile, there's a huge untapped pool of competent pathologists' assistants who are interested in working in a forensic capacity.

The capabilities of pathologists' assistants are likely met with a degree of skepticism from some forensic pathologists.

Since part of a forensic pathologist's job involves testifying in court cases and since pathologists' assistants are not physicians, any testimony they give is likely to be scrutinized by lawyers who would question their credentials. But do pathologists' assistants actually need to testify? If they are under the supervision of a pathologist, it may not be necessary.

While most hospital autopsy cases don't go to court, the rare ones that do don't subpoena the pathologists' assistant, as they are not responsible for rendering the diagnosis. In forensic settings, there are several examples of individuals who fall under the supervision of the forensic pathologist during an autopsy who aren't subpoenaed. Autopsy technicians are essential to every forensic office but aren't considered experts. Medical students, pathology residents, and pathologists' assistant students perform forensic autopsies as part of their training. They too are not required to appear in court.

Pathologists' assistants could practice under a similar scope that would be limited to simple overdose, suicide, or natural-death cases which do not require court testimony. These types of cases are responsible for most of the backlog in medical examiner's and coroner's offices. By performing autopsies, preparing reports, tracking toxicological results, and assisting with teaching, outreach, and education, pathologists' assistants could be a great asset to any office.

Pathologists' assistants may not be the answer to the "autopsy crisis" but might provide a solution to some of the problems forensic pathologists face. While they cannot replace forensic pathologists, pathologists' assistants can certainly alleviate the backlog of cases by reducing the buildup of bodies and facilitating workflow in a cost-effective manner.

Alyse Gray is a pathologists' assistant and writer who has authored two books. She holds an associate degree in mortuary science, a bachelor's degree in psychology from Geneva College, and a master's degree in pathology from the University of Maryland, Baltimore.

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