Academy Aperçus—August 2022

The Academy Aperçus is a monthly feature that celebrates 75 years of forensic science by spotlighting the history and anticipating the future of each section of the Academy. Beginning in March and progressing through each section in the order of acknowledgement by the Academy, a senior member will join with a junior member to memorialize salient events, highlight members, and provide insight into why the Academy remains the premier forensic science organization in the world. This month features the Pathology/Biology Section.

AAFS Pathology/Biology Section 1998 to 2023

Source: Edmund R. Donoghue, MD, AAFS Past President and Pathology/Biology Section Fellow

From 1998 to the present, the state of forensic pathology has gone from excellent to good to fair. At the beginning of the Academy's third quarter-century, most medical examiners' offices met their needs for forensic pathology trainees. Most trainees who wanted to work in the field could find employment. Many medical examiner systems enjoyed excellent funding and infrastructure.

The Great Recession of 2008 brought severe budgetary restraints and many medical examiner systems faced significant problems in funding for personnel, infrastructure, and technology. Local and state governments converted defined-benefit pension plans to defined-contribution plans.

In 1999, forensic pathologists began to see a rise in prescription opioid deaths, the second wave of heroin deaths beginning in 2010, and the third wave of synthetic opioid (principally fentanyl) death beginning in 2013. Handling these drug overdose cases severely taxed nearly all medical examiners' systems.

The number of homicide cases and the use of a semiautomatic weapons greatly increased during the period. In 1974, at the beginning of the Academy's second quarter-century, a homicidal gunshot case frequently consisted of a single gunshot. Currently, multiple gunshot are the rule, which markedly increases the complexity of these cases.

Beginning in 2019, in the region of Wuhan, China, a novel coronavirus emerged in humans. This new virus, COVID-19, spread incredibly quickly among people, due to its newness — no one on earth had an immunity to COVID-19 because no one had COVID-19 until 2019. The pandemic caused increased mortality throughout the world. Also, it challenged medical examiners when their personnel could not handle the increased volume of cases or could not report for work because of illness or exposure to COVID-19.

Many medical examiners have retired and others have left the field of forensic pathology. Medical examiner systems are now experiencing great difficulty filling their vacant positions in forensic pathology and other disciplines. This takes its toll on remaining staff, who must work shorthanded.

There is a bright spot in this story. The use of radiology is extremely valuable in locating and documenting bullets, foreign objects, fractures, medical devices, and personal effects on bodies. Radiology is also helpful in documenting abnormal fluid and gas accumulations in various body cavities. When visual and fingerprint identification cannot be conducted, dental and other diagnostic X-rays taken after death may prove or exclude identification by comparison with dental and clinical diagnostic X-rays taken before death.

Nearly all medical examiner offices have access to radiology technology. While some offices use only conventional cathode tube X-rays with film detection, others now have digital X-ray imagining that is viewed on computer monitors and stored and transmitted electronically. Some office also have fluoroscopy with image intensification for special examinations, including precisely locating bullets. Probably the most significant development in imaging implemented by forensic pathologists during the quarter century was LODOX®. This technology can produce a full-body X-ray scan in 13 seconds with lower radiation than conventional diagnostic X-rays.  Previously owned, reconditioned LODOX® scanners are now within the reach of medical examiner budgets. Select medical examiner offices now have access to computerized axial tomography (CAT scan). This unique imaging technology produces cross-sectional images of the body using X-rays and a computer.

Currently, the interest of hospital pathologists in performing autopsies is diminishing, and forensic pathologists perform the vast majority of autopsies. At present, medical examiner offices do the bulk of training regarding the performance of autopsy. Eliminating the requirement for hospital pathologists to be trained in forensic pathology would virtually stop autopsy training for hospital pathology residents. Because hospital residents in anatomic pathology would no longer be trained in medical examiner offices, they would no longer be exposed to forensic pathology. Additionally, they could not be recruited as forensic pathology fellows and future medical examiner.

Prior to January 1, 2006, certifications issues by the American Board of Pathology (ABP) were granted for life and did not require further maintenance. As of January 1, 2006, all new primary and subspecialty ABP certificate holders must participate in the ABP Maintenance of Certification (MOC) program, performing all program interim requirements and meeting all deadlines during its 10-year cycle. If a certificate holder does not meet reporting deadlines, a warning followed by expiration of the certificate occurs. The ABP's MOC program concentrates on four areas: (1) professionalism and professional standing; (2) lifelong learning and self-assessment; (3) assessment of knowledge, judgement, and skills; and (4) improvement in medical practice. Certificate holders report progress in meeting their requirements every two years and must pass a secure examination during every ten-year cycle. Maintenance of certification and re-certification examination requirements for all physicians and specialties have become burdensome and some states have tried to require MOC as a condition for medical licensure.

Standards for accreditation of medical examiner offices and autopsy guidelines are becoming increasingly detailed and rigorous, particularly in staffing requirements and the limits on the number of autopsies that medical examiners may perform. As originally devised, accreditation and autopsy guidelines set the minimum requirements for medical examiner offices. As time progressed, the standards have been ratcheted down and become more exacting. Today's guideline are becoming ideal or aspirational standards (i.e., a standard we would all endeavor to reach under ideal conditions). These standards may be reachable with adequate staffing, infrastructure, and funding, but may quickly become unreachable when resources are scare.

Medical examiners face continuing problems in funding for vitally needed equipment, personnel, and infrastructure. In addition, they face added regulatory burdens from their specialty board, accrediting organizations, and government.

"One side will make you grow taller, and the other side will make you grow shorter."1

Source: Jennifer L. Rhinesmith-Carranza, PhD, Pathology/Biology Section Student Affiliate

I feel like the Caterpillar has been forcing this dichotomy on me my entire life. Pick a side, Alice. Choose a path. Which pill is it, Neo? Blue or red? Even Frost had to make a choice between his two roads.

Perhaps I should back up a bit.

I've spent most of my life straddling the solid line we often draw between creativity and science. I loved to craft stories. I relished narrative. But I also love the creepies and the crawlies — the tiny water boatman looking like a little insect sea turtle as he takes his dive; the wandering maggot making its cross-country trek away from remains to find a place to pupate. I have always been unwilling to pick a side, and so I chose to forge my own path forward pursuing both. I finished my undergraduate time nearly a decade ago with two bachelor's degrees — one studying books, the other studying bugs — and I do routinely have to explain that yes, I do have a degree in English and no, I did not mean etymology — I meant entomology.

I find it so interesting that this pairing routinely short circuits conversations, because, to me, they are two sides of the same coin. A fundamental component of my liberal arts degree is an emphasis on communication, and a fundamental component of our science is the ability to communicate it to a wider audience. Especially in forensic disciplines, the ability to translate what we do in the laboratory, or the field, or under the microscope into accessible, applicable packets of information is essential.

I ended up in forensic entomology by accident, really. I took one elective class, which led to another, which led to an undergraduate research experience at the Forensic Laboratory for Investigative Entomological Sciences at Texas A&M University that spurred a passion that has led me to a doctoral degree in entomology. I have horrified past roommates and my spouse many times over throughout the years as they reached into the freezer for a pint of Ben & Jerry's® and came out instead with a Tupperware® full of insects waiting to be pinned. I have come home from the field smelling like death, quite literally, more times than I can count. As I near the end of my doctorate and look back over a decade ago to the English major who added that entomology course to her schedule "just for fun," I am struck by how many of us actually end up in Pathology/Biology and other AAFS disciplines through a series of fortunate events or happenstance that lead to lifelong passions for using science to support the pursuit of justice.

Ultimately, what we do as Academy scientists and forensic practitioners is engage in service: our science serves to push the boundaries of the known world and make it a safer, healthier, or simply more comprehensible place, and our work in relating this science to its forensic applications serves the pursuit of justice. As I look forward to the future of Pathology/Biology, I cannot help but look at it through my own lens of multidisciplinary study, and foresee that as an integral part of our section's future: cross-section collaboration. Many researchers have for too long remained siloed in their expertise. I envision the next 10, 20, or 75 years of the Academy continuing to embrace collaborative efforts between sections. Entomologists, medical examiners, toxicologists, anthropologists, and beyond all coming together to complement and enhance the work each of us does within our expertise. Pathology/Biology is not just pathology, not just entomology — it is so much more.

"But I don't want to go among mad people," Alice remarked.

"Oh, you can't help that," said the Cat. "We're all mad here. I'm mad. You're mad."

"How do you know I'm mad?" said Alice.

"You must be," said the Cat, "or you wouldn't have come here."1

While I don't consider those of us in Pathology/Biology "mad," per se, I do think there is an insatiable curiosity that connects many of us to one another and drives us through the looking glass. It is what enables us to push the boundaries that currently limit what we know about the world and advance our science. And in that lies the answer to the question I've been asking myself my whole life: creativity or science? Blue pill or red pill? The answer is both. Science itself is inherently creative; it requires creativity, unconventional thinking, and the ability to communicate what we discover when we use those idiosyncratic thoughts to pull back the curtain on the unknown. Curiouser and curiouser…

1. Carroll, Lewis. Alice's Adventures in Wonderland. Macmillan, 1865.