Kentucky has historically been considered a national model in its death investigations. It was the first state to implement a dual coroner and medical examiner system, something it’s had in place since 1973. That has given the state an important balance of elected leadership and forensic know-how. Coroners are elected county officials responsible for investigating any death that’s deemed unnatural. Once elected, they go through death investigation training with the Kentucky Department of Criminal Justice and are expected to keep up 18 hours of continuing education. They work with state medical examiners to determine the exact cause of death and decide whether an autopsy or toxicology test is needed, which a medical examiner would have to perform.
But it’s a system that has been strained in recent years. Pollard, who also serves as director of the Kentucky Coroner’s Association, made headlines last year for convincing one state medical examiner to stay on after the doctor had announced his resignation, citing a lack of funding and resources to properly do his job. The National Association of Medical Examiners recommends that professionals not perform more than 250 autopsies a year; Kentucky is averaging about 280, according to Pollard. “We need two more doctors. That would ease our caseload tremendously,” he says. In Henry County, Pollard used to investigate around 26 cases in his county per year in the 1990s. In recent years, that number has risen to around 66.
These issues aren’t singular to Kentucky. Coroners, medical examiners, forensic pathologists -- and people who wear more than one of those hats -- say their profession is more vital than ever before, particularly in the midst of the opioid epidemic. But low pay, long hours and heavy debt loads carried by young physicians make it hard to recruit and retain talented people.
America’s system for investigating deaths is a patchwork quilt of different laws, procedures and job descriptions. From state to state -- and even from one county to the next -- there can be variations in how sudden deaths are handled. “Unlike primary care or obstetrics, it’s the one specialty in medicine that’s practiced differently depending on where you live,” says Gregory Davis, former associate chief medical examiner for Kentucky.
Confusing matters even more, qualifications for each title also vary depending on state statute. Coroners are overwhelmingly an elected or politically appointed position, a tradition that dates back centuries to when they were simply tax collectors for the deceased; America’s first coroner took office in 1636 in Plymouth County, Mass. Some states require a coroner to be a physician; other states only stipulate that you must be 18 and have no felony convictions.
Medical examiners, on the other hand, must be licensed physicians. But even among the states that rely on medical examiners instead of coroners, there can be inconsistencies: A medical doctor doesn’t necessarily have a background in forensics, which is key for accurate autopsies. “How much death investigation training did we get in medical school?” Davis asks. “None.”
There’s been a debate raging for several years in the fields of death investigations and forensic pathologists on the right path forward. The National Academy of Sciences recommended in 2009 to abolish the coroner system and transition fully to using medical examiners for all death investigations. It’s a move that’s gaining some traction: Sixteen states and the District of Columbia now only have medical examiner offices. Eleven states just use coroners, and the rest have a mix of medical examiners and coroners, all with different qualifications and hierarchies. However, in states with a mix of both, coroners usually handle the death investigation, and medical examiners handle the actual medical aspect of it, like completing autopsies.
Kim Collins, the president of the National Association of Medical Examiners, says she understands where the National Academy of Sciences is coming from with the recommendation to move solely toward the medical examiner system. But she argues that it ignores the larger problems of funding, resources and culture that can’t be fixed by a title change. “One size isn’t going to fit all,” she says. It’s an entrenched system and “these coroners have been here since colonial times. You’re just going to have to improve research and training.”
In many states, the office of coroner operates with a surprising lack of accountability. In 49 of California’s 58 counties, for instance, the coroner is also a sheriff, which experts say is a severe conflict of interest. In San Joaquin County earlier this year, a forensic pathologist accused the sheriff-coroner of pressuring him to change autopsy findings in cases that involved law enforcement. A 2016 county audit found that the same thing had happened four times that year. Similarly, a forensic pathologist in Boulder County, Colo., sued the coroner’s office in June, arguing that she was wrongfully terminated for refusing to change the manner of death on a death certificate when the coroner insisted. Colorado is a coroner-only state that stipulates merely that the elected coroner go through death investigation training.
“The bad systems are the ones where people without medical training think they can do it all,” says Mary Ann Sens, the coroner for Grand Forks County, N.D. Sens says she is the only coroner in the state with a forensic pathology background. She doesn’t have a problem with coroners not holding medical degrees, she says, as long as they defer to or consult with an independent medical professional, similar to the Kentucky system. “The real hallmark [of a good system] is when medical decisions are made by a medical professional and are independent. If there was a jail death, I need to be able to say law enforcement messed up.”
Flipping through primetime network television, it would be easy to assume that America is overflowing with medical examiners. More than a dozen shows in recent years have centered on coroners or examiners. But the reality is that it’s becoming extremely hard to find enough qualified professionals to fill the job. There are currently only 500 board-certified forensic pathologists in the U.S., which is less than half of what the National Association of Medical Examiners recommends.
Part of the problem is low pay. “It’s the one subspecialty of medicine where your pay goes down once you get that training,” says Davis, the former examiner in Kentucky. On average, public-sector forensic pathologists make about half of what a primary care doctor in a private practice can make. And with medical student debt averaging near $150,000, accepting a public-sector job with a public-sector salary isn’t enticing for many newly minted doctors. “Whenever I have a presentation about my job, the first slide always says, ‘I have the coolest job in the world,’ because I do,” says Andrew Baker, chief medical examiner of Hennepin County, Minn. “But I’m worried about my profession. At the risk of sounding crass, the economics of being a forensic pathologist don’t make sense when compared to a pathologist at a private hospital.”
The shortage of examiners has been worsened exponentially by the current opioid crisis. “Prior to the opioid epidemic, we needed about 1,000 forensic pathologists across the country. So even before, we were already underserved by half,” Baker says. Now, thanks to the explosive rise in opioid deaths, he estimates that America needs “another 250 forensic pathologists just doing drug overdose autopsies.”
Coroners and examiners across the country have had to get creative to handle the surge of drug overdose deaths. The St. Louis County Medical Examiner’s office started using refrigerated trailers to hold bodies last year. Other counties have had to build more space or borrow room from local funeral homes or hospitals. Some jurisdictions are now forgoing a full autopsy and only conducting toxicology tests if an overdose is suspected.
(AP)
Despite the national attention on the drug crisis, its impact on coroners’ offices can be less well known. “I’m not sure how many lawmakers know who their medical examiner or coroner is, and know how many of the offices are on the brink of complete collapse,” Baker says. “They don’t have enough money to do routine examinations, so they are on the verge of losing accreditation.”
The Connecticut Office of the Chief Medical Examiner lost its accreditation briefly in 2017 when the National Association of Medical Examiners found the office had inadequate staffing and storage space for bodies. The Los Angeles County Coroner’s Office came close to losing its accreditation in 2016 because of delays in autopsies and toxicology tests.
Back in Kentucky, Pollard says he is continually lobbying the county judge for a bigger budget, which isn’t easy. “I tell him that I can’t say how many cases I’m going to have, but I am going to have to complete them. More people are just dying in ways that need to be investigated,” he says.
Davis similarly recalls asking a state lawmaker for more resources. The lawmaker responded, “Dead people don’t vote,” he says. “I said, ‘No, but their pissed-off relatives do.’ Like so many things, this just comes down to an issue of money.”
Spending more on death investigators isn’t just important for keeping track of overdose deaths and giving closure to loved ones. It can be a vital public health tool in identifying new diseases and alerting the public to new strains of potentially lethal viruses. “When deaths are adequately investigated, you notice patterns. In Albuquerque, for example, they are seeing a lot of respiratory-related deaths this year, which was pinpointed to be caused by deer mice urine,” Davis says. “We’re on the frontline of public health surveillance. An investment in medical examiners and county coroners’ offices is an investment in public health. By learning how people die, it helps us all live.”
