Summary of Public Comments on SWGMDI PRC5: Increasing Forensic Pathologist Supply Page 1

Summary of Public Comments

PRC5: Increasing the Supply of Forensic Pathologists in the United States

Prepared by the SWGMDI Board of Directors

September 30, 2012

Introduction

The SWGMDI Document “PRC5: Increasing the Supply of Forensic Pathologists in the United 

States” was posted for public comment between June 22 and September 22, 2012. All 

comments received were reviewed and addressed by the SWGMDI Board. This report includes 

all comments received and the SWGMDI’s response to the comments. 

Overall Results

Comments were received from 22 individuals and from 2 organizations. Responders included 

forensic pathologists (7), professors (5), non-MD coroners (2), laboratory director (1), training 

director for a security business (1), Pathology Department Chairman (1), criminalist (1), 

physician research administrator (1), autopsy supervisor/investigator (1), pathologist (1), and 

pathology assistant (1). A formal response was received from the College of American 

Pathologists and the National Association of Medical Examiners.

Comments Received and SWGMDI Reponses to Comments

There is no shortage of Forensic Pathologists. As evidenced by my own experience. I have extreme 

difficulty finding a job. When I do manage to find a job the salary is half that of a surgical pathologist. 

Often, I receive no call back to my application. 

RESPONSE: This response is from a personal perspective and involves factors other than those related to 

lack of forensic pathologists in some areas of the country. No changes made.

The changing nature of pathology education in medical school probably doesn't have much effect on 

students going into forensic pathology.

Needs some grammar updates Line 21, Spell out SWG. Spell out all acronyms on first use.

Line 30, Spell out ACGME. Spell out all acronyms on first use.

Line 38. Don't start sentence with a number. Spell it out.

Line 39, Replace ""of the"" by ""of these"".

Line 40, insert comma following fellowships

Line 57, insert comma following filled

Line 60, Replace ""less"" by ""fewer""

Line 75, Replace ""Forensic pathologist salaries"" by ""Salaries of forensic pathologists""
Summary of Public Comments on SWGMDI PRC5: Increasing Forensic Pathologist Supply Page 2

Line 77, Replace ""100K"" by ""$100,000"" and ditto for 200K, These are too colloquial for this 

important document.

Line 80, Regarding ""Rural areas also complicate"", This is not true. A rural area cannot complicate. 

Humans complicate.

What you want to say is that: Insufficient funding in rural areas because of low mortality rates and tax 

bases makes it difficult to support financially board-certified forensic pathologist is many rural areas of 

the United States.

RESPONSE: The document was edited to reflect these changes except for lines 13-14, which is a 

debatable statement. 

Line 81, correct the split infinitive. Change to ""to justify fully"".

Line 86, Spell out all acronyms on first use. including SWGMDI

Line 89, Spell out all acronyms on first use. including PGY

Lines 90 and 91. Same comments as line 77.

Line 93. Consider replacing ""such"" by ""satisfactory"". A comma is needed after ""salaries"".

Line 105, A comma is needed after ""deaths"".

Line 106, Replace ""via such"" by ""by"".

Line 107, A comma is needed after ""purposes"".

Line 126 Delete the period after discipline

Line 138 Eliminate the split infinitive. Write ""to reflect better""

Line 155, Replace ""getting"" by ""obtaining""

Line 167, Delete the comma after students

RESPONSE: The document was edited to reflect these changes

"

Care needs to be taken at the medical school level to insure that whatever the exposure is to forensic 

pathology, there is no additional expense incurred in the form of increased tuition...It would be much 

more acceptable if treated as part of a medical pathology residency program...Salaries should be 

consummate with the industry norms and risks associated with this specific practice type....A very 

factually comprehensive document...Nice job...

RESPONSE: These points were incorporated into the document except for the statement about 

increased tuition.

It looks like your draft is well put together with documented reasons and data to back up your 

statements. The only thing I would recommend is to make your objectives measurable. For instance, 

how are you going to measure "cooperation"? 

RESPONSE: Subsequent documents may address measureable outcomes but it is premature to address 

them at this time. 

80-86: What about including forensic pathology in the designations of "underserved" areas that are 

similarly used for primary care?

RESPONSE: This concept was incorporated into the document. 
Summary of Public Comments on SWGMDI PRC5: Increasing Forensic Pathologist Supply Page 3

Thanks for the opportunity to offer response/comments to your draft report about recruitment 

difficulties in forensic pathology.

I am a pediatric intensivist ( pediatric critical care specialist). When I graduated from medical school, I 

matched with forensic pathology, and it has been my lifelong dream to return to it one day. I love 

histology and surgery! But, ultimately, I chose to see living children. I am boarded in both pediatrics 

and pediatric critical care medicine.

One thing to think about, in any serious consideration of manpower issues, is that requiring graduating 

medical students to make a permanent choice between seeing living patients, and practicing medicine 

for and on behalf of the dead is an awful lot to ask at that particular stage.

Whenever I inquire about how my considerable training and experience might be complemented and 

enriched toward forensic pathology now, at a later career junction, I receive almost no responses.

I have seen enough and done enough with critically ill and injured children, that I would now be able to 

make that commitment without reservation. And, I would be willing to undertake fellowship training for 

2-3 years in order to accomplish that. 

It is my own honest opinion that the forensic pathology field/boards themselves do not want qualified 

sub-specialists from other medical specialities/subspecialities to make this transition. At the very least, 

such a transition is not enabled, and I think that forensic pathologists perhaps bask a bit in their rarity.

RESPONSE : RESPONSE: These comments are of a personal nature and were not incorporated into the 

document. 

The facts as outline on these lines are not considered in a realistic context. And, my comments apply to 

realistic solutions; all subspecialties are facing serious manpower shortages at present.

Studies have shown that there is a shortage in all areas of healthcare as well as in the field of pathology. 

The specialty of pathology attracts approximately 1% or 1/100 medical school graduates. Thus a very 

short supply has been felt for many years. The profession "Pathologists' Assistants" has helped curb 

this shortage by the acceptance of allied health professionals willing to assist board-certified 

pathologists including board-certified forensic pathologists as healthcare extenders. Similarly the 

profession physician assistants and nurse practitioners provide services towards shortages in other areas 

of healthcare. "Board-certified Forensic pathologists represent less than 2% of the above mentioned 

board-certified pathologists and as shared in your article, many jurisdictions rely on people who may not 

have this necessary credential. A shortage of pathologists, pathologists' assistants and under validation 

or lack of an understanding of the value of the ""general"" autopsy or the ""forensic"" autopsy 

mentioned in your article has existed for the 29 years that I have been a Pathologists' Assistant. If 

portrayal of crime dramas draw big audiences why is it that training programs aren't receiving the same 

draw? These dramas show that autopsies are for the living!

More affordable student loans for all forensic-related professionals is one answer. Another, I believe is 

the return of a 20-30% autopsy rate for each hospital that was a requirement for hospital accreditation 

until the 1960's. As Abraham Flexner reported in the early 1900's hospitals and medical training centers 

with the highest autopsy rates provided the best medical outcomes. Autopsy rates have plummeted 

below the 8.5% that was stated in your article yet, the outcomes correlation has been studied and 
Summary of Public Comments on SWGMDI PRC5: Increasing Forensic Pathologist Supply Page 4

remains true despite our current rates of misdiagnoses from reliance solely on medical technology. IN 

MY OPINION, until the consumer and the medical community demand the return of autopsies and then 

recognize those who perform these procedures, the shortages will not change. My hope is that we can 

work together as medical consumers, healthcare professionals, insurance providers and become 

proponents towards (as Stephen Cina M.D. of the CAP Forensic Pathology Committee commented) ""A 

general autopsy itself is a very valuable tool in medicine"" and it is also a very valuable tool in justice, 

medical research and so many other facets of our wellness. 

The document is an excellent high level view of the issues with some potential specific solutions. The 

shortage of FPs is currently a very real problem and the time to implement these proposals (if any 

actually happened) would take years and then it would require many additional years to reap the 

downstream benefits of more FPs. Although the topic of the paper is to address a shortage of FPs it 

would also be useful to address, in my opinion, potential short and intermediate range solutions. 

Recruiting FPs shares similarities with recruiting physicians to rural locations and general primary care 

practices. The use of mid-levels is very common in medicine and can provide a mechanism to leverage a 

small number of physicians. I think the use of mid-levels (eg. pathology assistants) should be considered 

as a possible solution to this acute shortage of FPs. It is much easier for me to imagine a development 

of a 1 yr. FP training program for PAs that are already working (and trained in performing autopsies)as a 

relatively rapid response to the shortage issue. The idea of a FP supervising a small group of PAs on 

several cases (similar to what occurs in anesthesia) would also potentially allow regional offices with 

greater volumes of cases to develop (saving on resources and increasing access to expensive testingforensic radiology).

RESPONSE: We have included a reference to the National Association of Medical Examiner’s Position 

Paper on the use of pathologist assistants in forensic pathology. We also added reference to more 

affordable student loans. 

When I have had to fill vacant positions I have had no shortage of applicants. Those that percei a 

shortage should look at the salaries of the specific positions. In other words, those people who claim 

there is s shortage are usually offering a low salary for a large amount of work. If you offer a good salary 

you will have no shortage of applicants. My concern would be that bureaucrats are trying to increase the 

number of forensic pathologists so they can continue to offer low compensation or even lower 

compensation.

RESPONSE: Yes, there are places in which jobs are attractive. This comment does not address the lack of 

forensic pathologists in some areas of the country. We have no evidence that the last sentence has 

merit. 

P234 TO MAINTAIN THEIR PATHOLOGY PROGRAMS, MEDICAL SCHOOL AFFILIATED PATHOLOGY 

TRAINING PROGRAMS MUST PROVIDE THEIR RESIDENTS ONE MONTH TRAINIG IN FORNSIC PATHOLOGY. 

CHARGE FOR THIS TIME. IF ALL FORENSIC OFFICES DO THIS THEN THE UNIVERSITIES HAVE NO CHOICE 

BUT TO PAY. EXCELLENT PAPER

RESPONSE: We emphasized this in the revised document. 
Summary of Public Comments on SWGMDI PRC5: Increasing Forensic Pathologist Supply Page 5

Having gone through an RRC review during my fellowship year, I agree very much with this part. In

general I think the recommendations are helpful. I would omit the parts about loan forgiveness and 

increased fellowship year funding (it's one year, which doesn't matter in the grand scheme and 

applicants know this). The rest I like.

RESPONSE: We have clarified that forgiveness programs could involve medical school loans. 

Line 286 Insert a comma after ""factors"".

Line 288 Insert a comma after ""lessened"".

Line 293 Replace ""Review Committee (RRC)"" by ""RCC"" because it was, or should have been, defined 

in line 194.

Line 294 Isn't somewhat one word?

Line 295 Split infinitive. Write ""to practice successfully""

Line 297 Delete ""the"" following ""learning"".

Line 301 Replace ""be able"" by ""enable supervisors"".

Line 302 Insert a comma after ""methods""

Line 303 Insert commas after ""ACGME"" and ""methods"". 

Line 303 Replace ""have"" by ""need"".

Line 314 Insert a comma after ""positions"".

Line 317 Insert a comma after ""office"".

RESPONSE: The document was edited to include these suggestions.

Overall, it is a good effort. I think we can make some minor improvements:

1. get the CAP's 2011 Practice Characteristics Survey. I believe it shows that AP/CP folks make around 

$280000 base + $60000 incentives. and we have trained a year more than many of them.

2. in the recommendation for loan forgiveness, I would not apply it to ""pathology and forensic 

pathology."" Pathology can take care of itself-limit it to FP.

3. I think I did a NAME survey a few years back that looked at the incidence of depression amongst FPs 

as well as physical injuries. It could provide some additional background info.

4. Since the CAP has recently defined the autopsy as the practice of medicine, consider working with 

CAP and CFSO to have autopsies covered by CMS. It would also fit into Obamacare's concept of resultsdriven medicine.

5. I think many residency training programs would shut down without the autopsies we provide. You 

mention this but I really think we should strongly leverage this fact.

6. I think that those FP programs affiliated with residency training hospitals need to be able to take 

advantage of university/hospital assets that will help them handle the ACGME process. Perhaps the 

residency training coordinator can do some of our paperwork.

7. Can we make reference to the NAS recommendation that only Board certified specialists will be 

allowed to testify in court one day? Without enough FPs, the legal system grinds to a halt.

RESPONSE: We edited the document to reflect the thoughts in items 1, 2, 5,6, and 7.

I have spoken to numerous medical students and residents and one reason why many of them do not 

want to go into forensic pathology is because of the coroner system, and even worse the sheriff-coroner 

system in California. Many physicians after spending over ten to twenty years in training to become 

specialists find it very unappealing to work under someone who is not a physician and who has no 
Summary of Public Comments on SWGMDI PRC5: Increasing Forensic Pathologist Supply Page 6

inkling or basic understanding of medicine. In some jurisdictions, a forensic pathologist works under a 

sheriff and is supervised by a police officer who may have only a high school diploma. The coroner 

system is a very primitive system, which should be eradicated. I think it will become more appealing to 

medical students and residents to become forensic pathologists, if the coroner and sheriff-coroner 

systems are replaced by medical examiner systems nationwide. Medical examiner systems are more 

professional and sophisticated, and provide better services to the community at large especially with the 

fastly changing medical technology and medical sciences. 

RESPONSE: The issue of coroner versus medical examiner systems will be addressed in another 

SWGMDI document, probably in 2013. 

The document does a very good job illustrating the issues surrounding the hiring and retention of 

forensic pathologists in the United States. It clearly explain why there is a deficiency of forensic 

pathologists across the nation: lack of forensic pathology programs, lack of medical student interest, 

lack of funding, inadequate salary, large time commitment, etc.

The needs are clearly presented and the recommendations for meeting those needs are sound. 

I would also like to add the following:

1) Several new medical schools have opened/are opening throughout the United States. The 

mission of many of these schools is to train new primary care physicians. There is a tremendous 

need for primary care physicians across the U.S. The reasons for a lack of primary care 

physicians is very similar to the lack of forensic pathologists: lack of interest by training 

programs and students who prefer to focus on specialties, inadequate salaries, large time 

commitment, lack of respect, etc. It might be a good idea to encourage these new medical 

schools to also offer forensic pathology training programs as part of their curriculum. The need 

and the reasons for that need is very similar. 

2) The public needs to be made aware of the need for forensic pathologists across the nation. 

Follow the example of primary care physicians by publicizing the needs through local and 

national media. Public support will encourage local, state, and national officials to act.

3) Need to improve student interest. Recruitment needs to begin at the undergraduate level. The 

field can attract undergraduate students by offering undergraduate student internships, offering 

undergraduate forensic pathology courses and concentrations, visit schools during career fairs 

and/or offer to give talks. Early recruitment efforts will increases that chances that a student 

who is admitted to a medical school will pursue a forensic pathology specialty.

4) A higher salary will not be enough to recruit and retain forensic pathologists. The availability of 

proper equipment and proper facilities is imperative if the forensic pathologist is to perform 

his/her duties effectively. If the forensic pathologist feels that he/she can perform the job 

without obstruction, then job satisfaction will be high and will be able to attract new 

professionals and retain the existing ones. 

RESPONSE: The suggestions in items 1-4 were incorporated in the edited document. 
Summary of Public Comments on SWGMDI PRC5: Increasing Forensic Pathologist Supply Page 7

5) In addition to higher salaries, the forensic pathologist needs down time. The forensic pathologist 

needs more time off and longer vacation time to avoid physical and mental fatigue. This will increase 

the job satisfaction and job performance. We need to keep in mind that the forensic pathologist faces 

not just death, but gruesome death and witnesses the worst of humanity on a daily basis. Therefore, 

the job of the forensic pathologist is so unique and valuable that it deserves special recognition by

society. All suggestions to "short-cutting" the career path or developing "a forensic pathology training 

path" (lines 322 - 332) should be omitted. The document insists that residency training faculty must be 

supportive of those who are pursuing a career in forensics (line 193, for example). Shortening the 

training of forensic pathologists (here after, "FPs") will undermine those efforts and only isolate FPs 

further from other pathologists and physicians. The whole scope of pathology should be encountered 

during the residency of future FPs and cultivating a broad and integrative pathology training experience 

should be encouraged. If anything may be omitted it is the clinical pathology portion of residency. Even 

though the clinical pathology years are frequently not required to enter an FP fellowship, a combined 

AP/CP residency with subsequent FP fellowship is not too long or burdensome if only the earning 

potential were commensurate with the level of training! Salary is the key! PGY appropriate 

wages are not the problem, it is the salary of practicing forensic pathologists that turns people away 

from this career path.

Overall, very well written document.

RESPONSE: We have given greater emphasis to the need for improved salaries. We have eliminated 

reference to short-cutting.

Just one comment is the use of acronyms such as line 89 ""PGY"" or line 336 ""JCAHO"". These were not 

defined within the document and are not familiar to this reviewer. There were others and this 

document should be checked for undefined terms. 

RESPONSE: We have spelled out all acronyms, at least the first time they are used if they are used more 

than once. 

May want to include a Summary or Conclusion section to sum up the entire document prior to #10 

recommendation and the references. "

RESPONSE: We have added an Executive Summary at the front of the report which described the 

recommendations in bullet form. 

As example of novel funding mechanisms, the JCAHO should work with medical care funding sources to 

ensure payments to hospitals whose patients are autopsied by the medicolegal death investigation 

system or in-house (on site).This is long overdue; without the proper structure for Pathology in general, 

Forensic Pathology as a specialty will continue to decline with Pathology.

RESPONSE: This idea is a good one but also too complicated to address in this report. The SWGMDI may 

address this in a future document. 

I have mixed feelings about this [shortening training]. Even though I don't use my surgical pathology 

training in a classical sense (i.e. staging tumors), the immersion of it in residency taught me more 

intangible skills, like logic, classification and judgment. You still need to be aware of all of the entities out 

there. If you don't know about it, you won't think about it. I disagree about reducing microbiology 

training, since FPs are on the front lines of bioterrorism and infectious disease surveillance. 
Summary of Public Comments on SWGMDI PRC5: Increasing Forensic Pathologist Supply Page 8

RESPONSE: We eliminated reference to short-cutting. 

I would be very happy to offer a representative of the American Association of Pathologists' Assistants 

(AAPA) to share more about our profession and the struggle to attract qualified students into our US and 

Canadian training programs.

RESPONSE: See reference to NAME’s Pathology Assistant Position Paper

207-212 Special financial incentives for fellows is a must

217-230 The salaries have to be at least above the median for a general pathologist

260-269 A new and novel approach is needed. We need to create a Private fellowship programs by 

entrepreneurs who will contract various organizations for strict training purposes, incorporating all the 

resources available all over the world. We need to deal with this as national security issue. Forensic 

autopsy reveals a lot more than just cause of death it may reveal a whole new way of approaching 

dangerous diseases. Thanks

RESPONSE: Incentives and salaries were addressed in the document. The development of Private 

Fellowships would be difficult, if not impossible, to implement for multiple reasons. We did add the 

concept of national security. 

Line 228: How about DoD? NIH should divert some money from supporting ʺnovelʺ research to 

forensic pathology. Line 152: Is one hour enough for such a course? Line 324: Perhaps efforts need to be 

used to attract some foreign-trained professionals into this field. Salaries should be made competitive. 

Otherwise, it is going to be really hard to get enough forensic pathologists. However, it is easier said 

than done.

RESPONSE: We added reference to Do Din the report. We struck the one hour limitation to the proposed 

course. A sentence about NIH funding was added. At this point, foreign trained forensic pathologists 

might not be able to meet the board certification requirement that is being proposed, so we did not 

include this suggestion. 

lines 65, 137, 232

An obstacle to maintaining ACGME accreditation of forensic pathology fellowships that I have twice 

witnessed is the assumption by ACGME that the fellowship comes under the umbrella of a core 

pathology program, which in turn comes under the umbrella of an institutional DIO. Communication to 

and from ACGME about frequent changes in accreditation standards is assumed by ACGME to follow 

such a hierarchy. Free standing fellowships are vulnerable to missing important news and suffering the 

consequences during inspections. In 2014, pathology training will face a new paradigm shift at ACGME 

in the form of the Milestone Project and the Next Accreditation System. Although there are reasons 

why a forensic pathology fellowship may need to have separate administration from the academic 

center, all fellowships should have liaison with core pathology programs, and NAME should foster the 

participation of all forensic pathology fellowship directors in a community of interest in GME."

RESPONSE: We added to the report statements about the value of GME offices and their potential 

assistance in managing forensic pathology training programs.