SWGMDI’s Infrastructure Committee: Report on Relationships Between Pathology Departments 

and Medical Examiner/Coroner Offices 

Published 7/19/2013 Page 1

Relationships between Pathology Departments and Medical 

Examiner/Coroner Offices

A Report of Survey Results with Recommendations

Prepared by the Infrastructure Committee of the

Scientific Working Group on Medicolegal Death Investigation (SWGMDI)

Executive Summary

This project was undertaken by the Scientific Working Group on Medicolegal Death 

Investigation (SWGMDI) Infrastructure Committee to document the nature and perceived quality 

of relationships between medical examiner/coroner (ME/C) offices and affiliated hospital, 

university, or medical school pathology departments that together may offer forensic pathology 

fellowships or ME/C office rotations to pathology residents or medical students. Survey results 

are contained in this report and based on those results, the following recommendations are 

offered: 

 Forensic Pathology Fellowship Training Programs that do not have an affiliation with a 

medical school pathology department should consider pursuing a formal relationship.

 ME/C offices that have medical students and pathology residents rotating through their office 

should receive financial support from the affiliated institution, and forensic pathologists 

teaching medical students, residents, and/or fellows should be paid, at least in part, by the 

institutions from which these trainees come.

 Relationships between ME/Coroner offices and pathology departments should be formal with 

signed letters of agreement outlining expectations, deliverables, and financial support of the 

ME/C Office.

 Forensic Pathologists who regularly and consistently teach medical students, residents, or 

fellows should receive faculty appointment status and related benefits by the institution from 

which the trainees come. 

 Department chairs and Anatomic Pathology Directors should encourage their faculty to 

promote a positive image of forensic pathology (FP) as a career to medical students and 

pathology residents interested in FP.

 Pathology departments should consider hiring a forensic pathologist to direct the autopsy 

service, especially when such direction needs improvement.
SWGMDI’s Infrastructure Committee: Report on Relationships Between Pathology Departments 

and Medical Examiner/Coroner Offices 

Published 7/19/2013 Page 2

 Pathology Departments should encourage their affiliated forensic pathologists to provide 

periodic educational sessions for residents (especially since the Accreditation Council on 

Graduate Medical Education (ACGME) requires training in forensic pathology), and provide 

faculty appointments and compensation for doing so. 

 Pathology departments should encourage, foster, and support collaborative research projects 

between surgical/clinical pathologists, autopsy pathologists, forensic pathologists, and other 

specialties to foster clinical and translational research.

 Forensic pathology representation and visibility within the national pathology organizations 

should be improved by developing special projects and programs on forensic pathology and 

recruitment into the forensic pathology subspecialty

 Increase awareness of and opportunities to experience forensic pathology by medical 

students.
SWGMDI’s Infrastructure Committee: Report on Relationships Between Pathology Departments 

and Medical Examiner/Coroner Offices 

Published 7/19/2013 Page 3

Relationships between Pathology Departments and Medical 

Examiner/Coroner Offices

A Report of Survey Results with Recommendations

Prepared by the Infrastructure Committee of the

Scientific Working Group on Medicolegal Death Investigation (SWGMDI)

INTRODUCTION

This project was undertaken by the SWGMDI Infrastructure Committee to document the nature 

and perceived quality of relationships between medical examiner/coroner (ME/C) offices and 

affiliated pathology departments, which together may offer forensic pathology fellowships or 

ME/C office rotations to pathology residents or medical students. As background information, 

there are 37 ACGME-accredited forensic pathology fellowship training programs and 

approximately 147 academic pathology departments in the United States (1,2).

METHODS

With the cooperation of the Association of Pathology Chairs (APC), notice of an on-line survey 

was sent to each Pathology Department Chair via email in November 2011. A similar survey 

notice was sent to forensic pathologists in January 2012 using the National Association of 

Medical Examiners’ NAME-L listerv system, which includes approximately 500 forensic 

pathologist subscribers. Multiple reminders about the survey were emailed and the survey 

remained open to each group for 3 weeks, at which time response rates dropped to zero. The data 

were analyzed by an assigned group of SWGMDI Infrastructure Committee members in March, 

2012. 

RESULTS

Regarding the survey, 38 ME/C offices and 43 Pathology Department Chairs responded. The 

relatively low response numbers from ME/C offices is not surprising since there are only 37 

ACGME-approved forensic pathology training programs in the United States, and many ME/C 

offices in the United States do not have forensic pathology fellows, pathology residents, or 

medical students training in their offices. The response rate of 29% among Pathology Chairs is 

about the same as has been observed with surveys conducted by the National Association of 

Medical Examiners in the past. 

Among the 43 pathology departments, 33 (77%) had anatomic pathology training programs but 

not a forensic pathology fellowship program and an additional 7 (16%) also had a forensic 

pathology fellowship program. Thus, input from pathology departments was primarily from 

institutions that do not have a forensic pathology fellowship program.

Of the 38 ME/C offices that responded, 18 (47%) had a forensic pathology fellowship program. 

Thus, input from ME/C offices was not weighted toward institutions with forensic pathology 

training programs. For 13 ME/C offices that responded, responses were also obtained from at 
SWGMDI’s Infrastructure Committee: Report on Relationships Between Pathology Departments 

and Medical Examiner/Coroner Offices 

Published 7/19/2013 Page 4

least one affiliated pathology department. Thus, viewpoints from both “sides” were available for 

approximately one third of responders. 

In the following Tables, results are presented for the most relevant survey questions, followed by 

comments as needed: 

Question A: Is the pathology department supportive of Forensic Pathology as a career?

Comment: The perception of the quality of support differed among the ME/C responders and 

the Pathology Department responders, with the latter perceiving a more supportive nature than 

was perceived by the ME/C offices 

For the programs that had responders from both the ME/C Office and the affiliated Pathology 

Department, the discordance of perceptions is also illustrated, with complete concordance in 

regard to only 2 programs. 

Question B: Could the pathology residents complete the 50 autopsies required for 

Anatomic Board qualification if the residents DID NOT do autopsies at the ME/C office?

Degree of Support ME/C responses

(38)

Pathology Department Responses (43)

Very supportive 36% 81%

Somewhat supportive 33% 16%

Not very supportive 21% 2%

Discourage 3% ---

No response 6% ---

(# of answers) ME/C responses Program responses

2 Very Very

1 Very Somewhat supportive

6 Somewhat supportive Very 

2 Not very Somewhat supportive

6 Not Very Very

Answer Options ME/C responses 

(38)

Pathology Department Responses (43)

Yes 25% 40%

No 43% 28%

Some would, some would not 19% 28%

Unsure 11% 2%

Unanswered 2% 2%
SWGMDI’s Infrastructure Committee: Report on Relationships Between Pathology Departments 

and Medical Examiner/Coroner Offices 

Published 7/19/2013 Page 5

Comment: Even though the perceptions of ME/C offices and Pathology Departments differed, it 

appears that in the majority of places, the ME/C office is needed for pathology residents to gain 

the requisite autopsy experience. 

Question C: Compensation of Forensic Pathologists:

Compensation ME/C responses (38) Program responses (43)

Employees of medical school 16% 28%

Stipend 16% 14%

None 50% 44%

Other 18% 14%

Comment: It appears that the majority of forensic pathologists who mentor forensic pathology 

fellows, pathology residents, and medical students are not employees of medical schools, 

although some (a minority) receive a stipend or other form of compensation for their teaching. 

Eleven (29%) of the responding ME/C offices indicated that their relationship with a pathology 

department was informal. 
SWGMDI’s Infrastructure Committee: Report on Relationships Between Pathology Departments 

and Medical Examiner/Coroner Offices 

Published 7/19/2013 Page 6

RECOMMENDATIONS

1) Forensic Pathology Fellowship Training Programs that do not have an affiliation 

with a medical school pathology department should consider pursuing a formal 

relationship.

Formal relationship with an academic pathology department has potentially tangible 

benefits. First, the fellowship might be paid for through the pathology department instead 

of government-based funding of the ME/C office, which is often in peril and can result in 

de-funding of fellowship training positions. A recent survey by the National Association 

of Medical Examiners shows that only 69% of ACGME-approved forensic pathology 

fellowship positions are funded, and in most cases, the places lacking such funds are in 

programs without formal medical school affiliations (3). Second, the resources of the 

medical school are more readily available in terms of expert consultants, laboratory 

services, and Graduate Medical Education (GME) Offices to assist with training program 

management and compliance. Third, stipends might be available to forensic pathology 

faculty, which could augment their traditionally low salaries provided by government 

funders of ME/C offices. 

If formal relationships are established between pathology departments and ME/C offices, 

care needs to be taken to avoid real or perceived conflicts of interest in regard to case 

management. For example, if a medical school has a hospital located within the

jurisdiction of the ME/C office, appropriate steps must be taken to avoid the perception 

that the ME/C investigation of a death in that hospital is possibly being compromised 

because of the relationship. This potential problem can be managed by ensuring that any 

compensation is for teaching and not for actual service work, and by establishing 

procedures for recusal in selected types of cases. 

2) ME/C offices that have medical students and pathology residents rotating through 

their office should receive financial support from the affiliated institution, and 

forensic pathologists teaching medical students, residents, and/or fellows should be 

paid, at least in part, by the institutions from which these trainees come.

Medical schools and residency programs often view residents and medical students 

rotating on various services as an addition to the work force, and that their presence is, in 

essence, compensation to faculty for teaching them. However, the truth is that trainees 

impose additional work because of the supervision required and the lengthening of time it 

takes to complete case work. Procedures should be developed to ensure that the 

pathology department financially supports the ME/C office through funding paid to the 

ME office and/or to its faculty for their teaching time. Anatomic Pathology training 
SWGMDI’s Infrastructure Committee: Report on Relationships Between Pathology Departments 

and Medical Examiner/Coroner Offices 

Published 7/19/2013 Page 7

programs are required to provide their residents with forensic pathology experience, and 

these programs should build into their budgets funding to support the ME/Office in 

exchange for the education and training the ME/C office provides. 

In the survey leading to this report, medical examiners and coroners were asked what 

type of compensation they received for teaching medical students and residents. 50% 

said that they received no compensation. In a similar survey given to pathology 

departments, it was reported that 44% of forensic pathology faculty received no 

compensation. Smaller percentages of programs and ME/C offices reported the forensic 

pathology staff receiving full salaries, stipends, or educational funds.

There are several issues that would support financial incentive for FPs training residents 

and medical students:

a. The amount of time teaching residents and fellows, along with the resources used 

(transcription, etc.) would make funding for residents and fellows seem 

appropriate.

b. According to FP and program responses in our survey, the majority of residents 

would not reach their 50 autopsy requirement without performing medicolegal 

cases. If FPs provide a service that is vital for the accreditation of the residency 

program, then it should be valued as much as the other rotations such as surgical 

pathology.

c. The quality of the training is affected by the encouragement/discouragement of 

the institution. Do the forensic pathologists feel that their time and effort is 

considered valuable?

d. In offices in which the forensic pathologists are paid by government agencies and 

not medical centers, the focus is not on academic achievement. The counties do 

not pay forensic pathologists to teach, and thus it is difficult to define what 

“percentage” of an FP’s time should be devoted to teaching (a non-funded 

activity). FPs should be paid for their duties that fall outside of their job 

descriptions, such as teaching.

e. Medical schools receive not only tuitions from students, but also Medicare and 

other funds to train the residents. It is appropriate that some of these funds be 

passed on to ME/C offices and forensic pathology staff who provide medical 

student education.

3) Relationships between ME/Coroner offices and pathology departments should be 

formal with signed letters of agreement outlining expectations, deliverables, and 

financial support of the ME/C Office.

Such a recommendation, to some extent, is already required for ACGME accredited 

residency programs (4):
SWGMDI’s Infrastructure Committee: Report on Relationships Between Pathology Departments 

and Medical Examiner/Coroner Offices 

Published 7/19/2013 Page 8

There must be a program letter of agreement (PLA) between the program and each 

participating site providing a required assignment. The PLA must be renewed at least 

every five years. The PLA should:

I.B.1.a) identify the faculty who will assume both educational and supervisory 

responsibilities for residents;

I.B.1.b) specify their responsibilities for teaching, supervision, and formal 

evaluation of residents, as specified later in this document;

I.B.1.c) specify the duration and content of the educational experience; and,

I.B.1.d) state the policies and procedures that will govern resident education 

during the assignment.

Perhaps more formal agreements between ME/C Office forensic pathologists should 

define compensation for their work. The ACGME requirements as listed above are all 

unidirectional: what a program can get from the ME/C office, but nothing about what the 

ME/C should get in return. Suggestions include: 

 Faculty appointments (this will likely vary from place to place, but we should 

suggest that the affiliations should be the strongest possible...not just clinical 

faculty if it is permissible to allow for regular faculty). 

 Monetary reimbursement in the form of faculty/staff pay. 

 Other benefits that typically accompany faculty appointments (education, 

book, and conference/continuing education travel funds, for example)

If the proposed arrangements are not satisfactory, or if either party does not abide by the 

agreement, the parties should be allowed to withdraw from the agreement or amend the 

agreement to make it workable and satisfactory to the parties involved. 

Full integration of a medical examiner office into the Department of Pathology has 

occurred in New Mexico, for example, such that all of the forensic pathologists are full 

time academic faculty and constitute a division of the department. Such a model benefits 

the clinical function of the medical examiner office and also enhances the education and 

research missions of the university. One benefit of university affiliation is that it helps to 

protect forensic pathologists from political retaliation if the pathologist must make a 

proper but politically embarrassing determination of cause and manner of death in a case. 

4) Forensic Pathologists who regularly and consistently teach medical students, 

residents, or fellows should receive faculty appointment status and related benefits

by the institution from which the trainees come. 
SWGMDI’s Infrastructure Committee: Report on Relationships Between Pathology Departments 

and Medical Examiner/Coroner Offices 

Published 7/19/2013 Page 9

5) Department chairs and Anatomic Pathology Directors should encourage their 

faculty to promote a positive image of forensic pathology as a career to medical 

students and pathology residents interested in FP.

The survey leading to this report showed that pathology departments have a different 

perception of positive “support” than do the ME/C offices and forensic pathologists. 

When asked if the pathology department was supportive of forensic pathology as a 

career, over 80% of the chairs responded “very supportive”, but only 36% of the forensic 

pathologists responded in the same way. This discordance needs to be rectified. 

It is very difficult to enforce positive encouragement. It may be more practical to say that 

department chairs should talk to their faculty about NOT discouraging forensic pathology 

as a career, in light of the need for increased numbers of forensic pathologists. Perhaps 

there could be some information provided to the department chairs through their APC 

listserv or the CAP, highlighting the dire need for FPs in the US. 

6) Pathology departments should consider hiring a forensic pathologist to direct the 

autopsy service, especially when such direction needs improvement.

7) Pathology Departments should encourage their affiliated forensic pathologists to 

provide periodic educational sessions for residents (especially since the ACGME 

requires training in forensic pathology), and provide faculty appointments and 

compensation for doing so. 

8) Pathology departments should encourage, foster, and support collaborative research 

projects between surgical/clinical pathologists, autopsy pathologists, forensic 

pathologists, and other specialties to foster clinical and translational research.

Some of the most valuable research occurs at the intersection of different or multiple 

disciplines. Research such as recommended here should include clinical and translational 

research projects that bring forensic pathologists into greater collaboration with other 

types of academic physicians and scientists. Further, clinical and research colleagues may 

have funds and expertise to broaden the role of forensic pathology in research.

9) Forensic pathology representation and visibility within the national pathology 

organizations should be improved.

Many pathology residents participate as members of the CAP and USCAP, and often 

attend at least one of the annual meetings during their residency. Exposing this group to 

forensic pathology through an aggressive marketing strategy (booths at the meetings, 
SWGMDI’s Infrastructure Committee: Report on Relationships Between Pathology Departments 

and Medical Examiner/Coroner Offices 

Published 7/19/2013 Page 10

focus groups giving talks at the meetings, or ads about forensic pathology in the general 

pathology journals) will increase recruitment into forensic pathology. NAME-driven 

workshops or resident social events at these national meetings may also be of benefit.

10) Increase awareness of, and opportunities to experience forensic pathology by 

medical students.

This recommendation might be fulfilled by establishing formal, one-month long electives 

for medical students who are considering pathology as a career, including the rotation 

description in whatever official “catalog” or online listing of electives the med-school 

has. Concentrating on medical students interested in pathology would make such 

electives more focused and cost-effective in terms of drawing people into the field of 

forensic pathology. Involvement of the Association of Pathology Chairs’ Undergraduate 

Medical Educator Directors group (U-MED) to incorporate more forensic pathology in 

medical school curricula may also be productive. 

SUMMARY

A survey has been conducted to document the perspectives of pathology department chairs and 

forensic pathologists about the nature and quality of relationships between pathology 

departments and medical examiner/coroner offices. Survey data were used to develop 10 

recommendations to improve said relationships.

References

1. Accreditation Council of Graduate Medical Education. ACGME-Accredited Training 

Programs in Forensic Pathology. Available at: http://www.acgme.org/adspublic/

Accessed June 21, 2012.

2. Brotherton SE, Etzel SI. Graduate Medical Education, 2010-2011. JAMA. 2011:306(9); 

1015-1030.

3. National Association of Medical Examiners. Graduating FP Fellow Transition Report for 

Fellows Completing Training in June 2012. National Association of Medical Examiners. 

Marceline, Missouri. June, 2012.

4. Accreditation Council of Graduate Medical Education. Common Program requirements. 

Available at:

http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/310forensic

path07012004.pdf

Accessed March 12, 2013
SWGMDI’s Infrastructure Committee: Report on Relationships Between Pathology Departments 

and Medical Examiner/Coroner Offices 

Published 7/19/2013 Page 11

The SWGMDI Infrastructure Committee members who participated in data collection, 

analysis, and report preparation include:

Barbara Butcher

John Fudenberg

Randy Hanzlick, MD (Presiding Officer)

R. Gibson Parrish, MD

Mary Ann Sens, MD PhD

Lindsey Thomas, MD

J Scott Denton, MD (Advisor)

Joe Prahlow, MD (Advisor)

Reade Quinton, MD (Advisor)

This document was approved for public release by the SWGMDI Board on July 19, 2013. 

At that time, the SWGMDI Board Members were:

Barbara Butcher, MPH

Steve Clark, PhD

Laura Crandall, MA

Tim Davidson, MBA-HA

John Fudenberg

Roberta Geiselhart, BSN

Randy Hanzlick, MD

Marie Herrmann, MD

Julie Howe, MBA

Bruce Hyma, MD

Donald Jason, MD JD

David (Zeb) Johnson

Danielle McLeod-Henning, MFS

R. Gibson Parrish, MD

Keith Pinckard, MD PhD

Lakshmanan Sathyavagiswaran, MD

Mary Ann Sens, MD PhD

Lindsey Thomas, MD

Frederick Upchurch

Margaret Warner, PhD

Amy Wyman