ArticlePDF Available

Reclaiming the Autopsy as the Practice of Medicine: A Pathway to Remediation of the Forensic Pathology Workforce Shortage?


Abstract and Figures

The historically constricted forensic pathology workforce pipeline is facing an existential crisis. Pathology residents are exposed to forensic pathology through the American Council of Graduate Medical Education autopsy requirement. In 1950, autopsies were conducted in one half of the patients dying in American hospitals and 90% in teaching hospitals, but they have dwindled to fewer than 5%. Elimination of funding for autopsies is a major contributor to the lack of support for autopsies in departments of pathology. Funding may require reclaiming the autopsy as the practice of medicine. Funding of autopsies would rekindle interest in hospital autopsies and strengthen the forensic pathology workforce pipeline.
Content may be subject to copyright.
Reclaiming the Autopsy as the Practice of Medicine
A Pathway to Remediation of the Forensic Pathology Workforce Shortage?
Victor W. Weedn, MD, JD* and M.J. Menendez, JD
Abstract: The historically constrictedforensic pathology workforce pipe-
line is facing an existential crisis. Pathology residents are exposed to forensic
pathology through the American Council of Graduate Medical Education
autopsy requirement. In 1950, autopsies were conducted in one half of the
patients dying in American hospitals and 90% in teaching hospitals, but they
have dwindled to fewer than 5%. Elimination of funding for autopsies is a
major contributor to the lack of support for autopsies in departments of pa-
thology. Funding may require reclaiming the autopsy as the practice of
medicine. Funding of autopsies would rekindle interest in hospital autop-
sies and strengthen the forensic pathology workforce pipeline.
Key Words: forensic pathology, pathology, workforce shortage, autopsy,
(Am J Forensic Med Pathol 2020;00: 0000)
The current forensic pathology (FP) workforce crisis in the
United States is well documented in national reports,
newspaper articles.
It is thought that there are currently about
500 practicing board-certified forensic pathologists in the United
States. The National Association of Medical Examiners (NAME)
reports there were 468 fellows in the organization in2019. A 2015
report calculated that 1280 forensic pathologists were needed for
the US population, based on the NAME accreditation workload
At that time, approximately 10% of FP positions were
vacant. Forensic pathologists are working harder; a 2019 survey
found that approximately 37% of forensic pathologists performed
more than 250 autopsies per year, which is a number in excess of
the number of autopsies recommended in the NAME Inspection
and Accreditation Standards.
The shortage has been dramatically
exacerbated by an opioid epidemic and evolving polydrug crisis
that has greatly increased the need for forensic pathologists.
The FP workforce can be seen as a subset of the pathologist
community, which in turn is drawn from the overall physician pool.
However, the education and training needed to become a board-certified
forensic pathologist requires this career choice to be made during
the education and training process. Therefore, the workforce pipe-
line that supplies forensic pathologists begins with medical students
choosing a pathology residency program and then pathology res-
idents choosing a FP fellowship; see Figure 1 and Table 1.
According to the Association of American Medical Colleges,
the total number of applications to US MD-degree granting medical
schools during the 2019 to 2020 academic school year was 896,819.
There were approximately 62,150 MCAT examinees per year
The Liaison Committee on Medical Education
currently accredits MD-degree granting medical schools and lists
152 accredited U.S. schools (2 pending) and 17 Canadian schools,
although the US News & World Report surveyed 185 medical
schools but ranked only 118.
There were 86,044 medical students
in US MD-degree granting medical schools in 2018 and 19,544
graduates to enter residency in 2019.
Added to these US MD-degree graduates are substantial
numbers of doctors of osteopathy (DOs) and international medical
graduates (IMGs) that enter the workforce pipeline; see Figure 1
and Table 2. The IMGs constitute approximately one quarter of
the incoming physician pool, but the number of IMGs becoming
part of the US physician supply could be significantly greater.
Despite recent increases in medical schools, the overall physician
supply is insufficient to meet the demand. The Federation of State
Medical Boards reported that in 2018, there were 985,026 actively
practicing licensed physicians (M.D. and D.O.) in the United
The Association of American Medical Colleges has projected
that there will be a shortage of up to 122,000 physicians by 2032.
Medical graduates, including MDs, DOs, and IMGs, enter post-
graduate training. In the past, medical graduates usually started their
training in a rotating internship before going into specialty train-
ing, but today's graduates generally directly enter a medical specialty
residency. A 2019 survey revealed that 136,028 medical graduates
entered US medical residency programs; see Table 2.
The gen-
eral need for medical residency positions is of such magnitude
that a 2019 bill was introduced in Congress to increase the number
by 3000 over the next 5 years.
Of the 11,490 medical specialty and subspecialty programs
accredited by the American Council of Graduate Medical Educa-
tion (ACGME), there were only 143 pathology residency programs
with 622 first year position slots and 582 first year pathology res-
idents filling these slots; see Tables 14.
Thus, of 136,028 med-
ical graduates, less than 1% of medical students choose to pursue
a pathology career.
The shortage of pathologists is greater than the overall physi-
cian shortage. The College of American Pathologists (CAP) has a
membership of approximately 18,000.
In 1983, a decline of 29%
of the number of pathology residency training programs was re-
ported during the period between 1978 and 1983.
In 2013, the
CAP hosted a Pathology Workforce Summit due to its alarm at
the dwindling number of students choosing a pathology career.
This historic summit brought together, for the first time, represen-
tatives of 20 pathology associations. Then CAP President, Stanley
Robboy, was the first author on the ensuing 2 papers published.
Dr. Robboy wrote:
Through 2010 there were approximately 18,000 prac-
ticing pathologists in the U.S. Our model projects
that the absolute and per capita numbers of practicing
Manuscript received February 13, 2020; accepted May 13, 2020.
From the *Department of Forensic Sciences, George Washington University,
Washington, DC; and NMS Labs, Horsham, PA.
The authors report no conflict of interest.
Reprints: Victor W. Weedn, MD, JD, Department of Forensic Sciences, George
Washington University, 2100 Foxhall Rd, NW, Washington, DC 20007.
* Presented at the N.A.M.E. Annual Meeting in Kansas City, MO on Oct.
22, 2019.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0195-7910/20/00000000
DOI: 10.1097/PAF.0000000000000589
Am J Forensic Med Pathol Volume 00, Number 00, Month 2020 1
Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
pathologists will decrease to approximately 14,000
full-time equivalent (FTE) pathologistsin the coming
2 decades. beginning in 2015, the numbers of pa-
thologists retiring will increase precipitously, and is
anticipatedtopeakby2021.this trend will continue
at least through 2030.
The general shortage of pathologists is now fully evident in 2019,
as was predicted.
Traditionally, pathology is taught during the first and second
(basic science) years of the medical curriculum, but many medical
schools now partially or fully integrate pathology into other curric-
ula (McMaster approach)resulting in a dwindling exposure to
the field.
After the completion of this course, most medical stu-
dents have no further exposure to pathology in their careers, un-
like all other medical specialties where exposure often begins in
the third and fourth clinical years and extends into postgraduate
training. A recent study on why medical students choose a pathol-
ogy career revealed 6 major influencing factors: (1) medical students'
accurate and inaccurate perceptions of the role of pathologists in
medical care, (2) the second year pathology course (teaching style
and personality were more important that content), (3) pathology life-
style, (4) the influence of student peers, (5) clinical experience and role
models, and (6) overcoming the negative pathologystereotypes.
Not only are medical students exposed minimally, if at all, to
pathologists, but they also often never see an autopsy.
In earlier
times, the Liaison Committee on Medical Education inquired into
the number ofautopsies performed when accrediting U.S. medical
It should be noted that it was a group of medical school
students who moved the American Medical Association (AMA)
to advocate for increasing the number of autopsies for them to
Furthermore, anatomy, which had once dominated early
medical education, has been reduced to short courses and increas-
ingly medical schools are eschewing actual human cadavers for
virtual ones.
Generally, about 3 to 4 dozen pathology residents proceed
from anatomic pathology (AP) or anatomic and clinical pathology
(AP/CP) to FP. JAMA reported that in 2019 there were 39 FP pro-
grams and 36 FP fellows in the United States (at a time therewere
582 first year pathology residents); see Tables 3 and 4.
Only about
one-half of the 78 FP fellowship slots are funded. The National In-
stitute of Justice has funded up to 10 FP fellowships since 2017.
It has been reported that 21% of the FP fellows do not go into FP
There is evidence that more forensic pathologists are
leaving than entering the field.
The shortage of forensic pathologists is more dire than it is for
hospital pathologists. Forensic pathologists comprise fewer than
3% of all pathologists. Of the 18,000 CAP members, only about 300
are forensic pathologists.
The immediate choke point in the FP workforce pipeline is
the shortage of medical students choosing pathology as a career
choice. Most departments of pathology have no forensic patholo-
gists as members of the faculty and anecdotal evidence suggests
that many pathology faculty members actively discourage their
pathology residents togo into FP. Pathology residents are exposed
to FP through an ACGME autopsy requirement. Often this require-
ment is met by sending pathology residents to the medical examiner's
office. However, support for this requirement is weak and dwindling.
In 1983, the then 100 autopsy pathology residency training re-
quirement was reported to be a major deficiency of various pro-
grams cited by the Residency Review Committee.
In 2014, the
Association of Pathology Chairs, in response to a call to abolish
autopsy frompathology training on the one hand and for morerig-
orous autopsy training on the other, formed an Autopsy Working
Group. The group consisted of 14 pathologists, including 3 foren-
sic pathologists (G.D., M.N., and B.S.).
They concluded that the
autopsy should remain a component of anatomic pathology train-
ing and the current minimum number of 50 autopsies should not
be reduced until the changes recommended above have been im-
plemented. This recommendation was conditionally implemented
as noted in a 2018 ACGME website:
Why are autopsies included in pathology residency?
[Program Requirements: IV.A.5. and UV.A.6.] The au-
topsy experience remains an important part of pathol-
ogy residency education. As an educational tool, it
serves to integrate medical clinical and scientific knowl-
edge, and clinical laboratory data and procedures. While
autopsy performance rates have declined nationally
and subspecialization has shifted professional prac-
tice patterns, pathologists entering practice do need
FIGURE 1. The Forensic Pathology Workforce Pipeline. Medical
graduates include US medical school graduates, graduates of
Doctors of Osteopathy schools, and international medical
graduates. Some of the medical graduate pool will enter US
pathology residency programs. Some of the pathology residency
graduates will enter US forensic pathology fellowship programs.
Some of the forensic pathology fellowship graduates will become
ABP board certified diplomats in forensic pathologyand enter the
US FP workforce.
TABLE 1. Workforce Pipeline (Rounded Numbers)
Board-Certified FPs
in Practice
~150,000 ~600 ~40 ~30
TABLE 2. Total and First Year Residents, Pathology Residents,
and FP Fellows (as of December 31, 2018)
Total First Year
Total 136,028 47,475
AP/CP 2261 582
FP 36 36
[Brotherton, Etzel, JAMA 322(10):9961016, 2019, Table 3. pp. 1002
& 1004].
Weedn and Menendez Am J Forensic Med Pathol Volume 00, Number 00, Month 2020 © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
to be able to perform medical autopsies and understand
their role in current practice.
Why are 50 autopsies required, and what types of au-
topsies count? [Program Requirement IV.A.6.f.] While
the requirement for 50 autopsies does not ensure res-
ident competence, it does ensure a certain level of ex-
posure to case material. The 50-autopsy requirement
will remain until a competency-based system can be
validated and implemented to potentially replace it.
The 8 components of the autopsy, as appropriate to the
case, are integral to the autopsy process.
The pathology competencies were subsequently published by the
Association of Pathology Chairs. The autopsy is a competency for
only 9 of 498 objectives.
Autopsy rates have plummeted.In 1950, autopsies were con-
ducted on approximately half of the patients dying in American
hospitals and 90% in teaching hospitals.
Hospital autopsy rates
are now thought to be less than 5%.
In fact, hospitals are gener-
ally now built without morgues.
Many reasons have been given for the decline,
their historical and continued value.
Abraham Flexner, in
his landmark 1910 report on the state of medical school education
in America, declared that good hospitals had high autopsy rates,
otherwise physicians would bury their mistakes.
More recently,
the media has echoed this sentiment:
Without autopsies, hospitals bury their mistakes. Hos-
pital autopsies have become a rarity. As a result, experts
say, diagnostic errors are missed, opportunities to im-
prove medical treatment are lost, and health-care sta-
tistics are skewed.
Many point to the elimination of an autopsy requirement for hos-
pital accreditation as the primary reason for the decline. The Joint
Commission on Accreditation of Hospitals (now Joint Commis-
sion on Healthcare Organizations) established a 20% to 25% au-
topsy requirement for hospital accreditation in 1965.
This was
understood in practice as 20% for community hospitals and
25% for teaching hospitals. This explicit numerical standard was
eliminated in 1970. The Director of the Joint Commission,
Dr. John Porterfield, described the decision:
it appeared to the Board, its Committee, and its ad-
visors that the previous benchmark of a nonqualitative
percentage of hospital death cases going to autopsy
was a rather insensitive approacha blind demand
only that the quota be reached. The Board therefore
chose the qualitative approach and ignored the fixed
The new requirement substituted a permissive appropriate
(qualitative) autopsy percentage, although the new Accreditation
Manual for Hospitals required appropriate audits, and encouraged
autopsies and clinicopathologic conferences.
Although the de-
cline in autopsy rates had begun before the new standard, the rate
dropped rapidly thereafter.
An unquestionably significant factor for the low rate of hos-
pital autopsies is the lack of funding for autopsies. One pathologist
wrote in 1962 that the autopsy is the only free medical service
remaining in medicine
and other pathologists claimed as early
as 1988 that the autopsy problem cannot be solved without solv-
ing the reimbursement problem.
For centuries, physicians performed autopsies on their own
patients at their own expense to further their own medical skills.
Sir William Osler performed over 1,000 autopsies of his own pa-
tients before he helped found the Johns Hopkins Medical School.
Care came to be provided at hospitals and the hospitals paid for au-
topsies as part of their expenses.
Public hospitals to serve the poor were established from the
birth of our nation.
Medical schools tended to be associated with
these public hospitals. Eventually, specialists, pathologists,per-
formed the autopsies and held clinicopathologic conferences that
served the broad educational need of hospital staffs.
The then
Dean of the Yale School of Medicine replied in responseto a ques-
tion as to whether hospitals should be reimbursed for autopsies,
Yes. It is an old problem as to whether this is patient care or ed-
Private health care insurance became available in the
TABLE 4. Diversity of Residents, Pathology Residents, and FP Fellows (as of Dec 31, 2018)
Total Female White Black Asian Hispanic Other
Total 136,028 61,980 (45.6%) 76,400 (56.2%) 7430 (5.5%) 36,033 (26.5%) 10,963 (8.1%) 5202 (3.8%)
AP/CP 2261 1128 (49.9%) 1211 (53.6%) 112 (5.0%) 651 (28.8%) 188 (8.3%) 99 (%)
FP 36 31 (86.1) 25 (69.4%) 2 (5.6%) 5 (13.9%) 5 (13.9%) 0
[Brotherton, Etzel, JAMA 322(10): 9961016, 2019, Table 2. pp. 1010 & 1012].
TABLE 3. Program and Source Data of Residents, Pathology Residents, and FP Fellows (as of December 31, 2018)
Programs Residents/Fellows USMDs IMGs DOs Canadians
Total 11,490 136,028 85,289 (62.7%) 31,238 (23.0%) 19,363 (14.2%) 138 (0.1%)
AP/CP 143 2,261 (1.7%) 1,040 (46.0%) 1,028 (45.5%) 191 (8.4%) 2 (0.1%)
FP 39 36 (<0.1%) 18 (50%) 10 (27.8%) 8 (22%) 0
[Brotherton, Etzel, JAMA 322(10): 9961016, 2019, Table 2. Pp. 998 & 1000].
USMD, US MD-degree
Am J Forensic Med Pathol Volume 00, Number 00, Month 2020 Autopsy as Practice of Medicine
© 2020 Wolters Kluwer Health, Inc. All rights reserved. 3
Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
century, but autopsies have not been covered
by health care insurance.
The US federal government began significant subsidization
of health care upon passage of the Medicare and Medicaid Act
of 1965.
At least initially, autopsies were intended to be paid by
Medicare but not Medicaid. However, in 1984, Dr. Lundberg noted
that a remarkable plummet commenced shortly after the enact-
ment of the Medicare law ...
Medicare reimbursement was through the Health Care Finance
Administration (HCFA, now the Center for Medicare and Medicaid
Services [CMS]). Medicare Part A included general hospital inpatient
services and Part B included specific physician services medically
necessary for specific individual patients. A Part Cwould have spe-
cifically covered hospital-based physicians such as pathologists, but
was dropped from the legislation just before its enactment. Part B
was applicable to surgical pathology and cytopathology and Part A
to hospital laboratory costs, but reimbursement for the professional
component of clinical pathology was left in limbomost pathologists
billed it as a Part B expense. The HCFA declined to recognize autop-
sies as a direct medical service to a patient payable from the Medicare
Part B trust fund.
The CAP advocated then and still advocates for
reimbursement as a physician service and billable on a reasonable
charge basisunder Part B of Medicare as a valuable physician
medical service.
The 1983 implementation of the Tax Equity and Fiscal Re-
sponsibility Act declared (§108) that professional medical ser-
vices personally rendered for an individual patient and which
contribute to the diagnosis or treatment of the individual patient
may be reimbursed under Part B, but services which are rendered
for the general benefit to patients in a hospital may be reimbursed
only on a reasonable cost basis under Part A.
Both the technical
and professional components of autopsies, could be reimbursed by
HCFA through part A. The HCFA would reimburse hospital-based
physicians for Part A services based upon the reasonable compen-
sation equivalents for the time actually spent by the physician. How-
ever, the shift from Part B to Part A reimbursement of the professional
component of clinical pathology services, created the erroneous
perception that such services were no longer covered.
Within a year, Congress passed further legislation that phased
in a prospective payment system by 1987. This system invoked
diagnosis-related groups as a basis of payment, in which the gov-
ernment would no longer pay based on actual costs, but rather a
set amount for a given diagnosis-related group. This law did not
require payment to pathologists and hospitals were strongly
dis-incentivized to pay pathologists for professional component
Then new legislation implemented the resource-based
relative value scale, to pay medical providers for Medicare services.
Currently, there is no assigned relative value for autopsies under
the resource-based relative value scale fee schedule, despite an
AMA's Current Procedural Terminology code and thus a patholo-
gist cannot bill for either the technical or professional component
of an autopsy as can be done for other laboratory services.
Thus, health care reforms have eliminated any federal funding
mechanism for autopsies. Since managed care organizations and
third-party insurers do not cover autopsy costs, hospitals are left
to absorb the expense. College of American Pathologists acknowl-
edges that CMS does not provide reimbursement for autopsies,
but opines that pathologists should be paid for their professional
Center for Medicare and Medicaid Services has not covered
the performance of autopsies, because they are not medically
necessaryprocedures for a specific patientas required by the
statutory language; essentially CMS does not view autopsies as
medical care or treatment of a patient. Initially, CMS (then HCFA)
would pay for autopsies as a general hospital good, whether viewed
as hospital staff education or a quality assurance tool; however,
this was not well understood by the pathologists, hospital admin-
istrators, and hospital counsel. Later, during transformations of
Medicare reimbursement in a quest to reduce costs, payments
for autopsies were disincentivized and then the mechanisms elim-
inated. Center for Medicare and Medicaid Services continues to
espouse that autopsies are valuable, but will not pay for the med-
ical skill and expertise to perform them.
Outside of this Medicare funding context, the autopsy is uni-
versally considered the practice of medicineas both a medical
procedure and the interpretation of the autopsy requires medical
expertise. In defining medical practice, the relevant sources of law,
include medical practice statutes, licensure board regulations, and
caselaw. A search of the Westlaw legal database by one of the au-
thors (M.J.M.) revealed that no court failed to recognize the au-
topsy as the practice of medicine, but that no case addressed the
federal funding of autopsies. State statutory laws are also in ac-
cord. Recently (2018), California enacted code 27522. (a) which
specifically declares: A forensic autopsy shall only be conducted
by a licensed physician and surgeon. The results of a forensic au-
topsy shall only be determined by a licensed physician and sur-
A review of the medical examiner and coroner statutes
reveals that 20 states (AZ, CO, CT, DE, FL, HI, IN, IA, KS,
KY, MD, NH, NM, ND, OK, OR, UT, VA, WV, WI) and the Dis-
trict of Columbia specifically make reference to forensic patholo-
gists performing autopsies, although autopsy assistants are used in
all of these jurisdictions.
CMS should recognize autopsies as the practice of medicine
and should pay for them. In a 1985 article, the former head of the
National Institutes of Health autopsy service wrote:
[I]f the autopsy is to be saved, it will take more than
the outcry of concerned physicians. The question must
be examined by health care policymakers and regula-
tory commissions, who are in a position to effect change.
It is commonly recognized that quality control procedures
and educational opportunities are not usually self-
funding. From a business perspective, the autopsy has
never been a lucrative procedure for pathologists.
Rather, it has been a service offered by pathologists
and subsidized by revenues gained from clinical pa-
thology laboratories, surgical pathology services, and
the general hospital overhead. We recommend that
the autopsy, as the most challenging and revealing
of medical examinations, be recognized as a physi-
cian service, billable on a "reasonable charge basis"
under Part B of Medicare.
In accordance with President Trump's Executive Order 13771,
Reducing Regulation and Controlling Regulatory Costs,CMS
conducted a review of its regulatory health and safety standards
and determined that the Medicare autopsy regulation CFR § 482.22(d)
is obsolete, duplicative, or unnecessary requirement.In September
2018, CMS declared:
We propose to remove the requirement for hospitals at
Sec. 482.22(d), which states that a hospital's medical
Weedn and Menendez Am J Forensic Med Pathol Volume 00, Number 00, Month 2020 © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
staff should attempt to secure autopsies in all cases of
unusual and of medical-legal and educational inter-
est. Because this requirement is redundant and more
detailed, specific requirements regarding medical-legal
investigative autopsies are required by individual
state law.
CMS recognized that this requirement contemplates medical exam-
iner and coroners cases governed by state law as well as cases of
unusual deaths or for educational interest performed as hospital
autopsies. CMS comments that the provision is redundant of state
law in cases of medicolegal autopsies, but eliminates the provision
for both medicolegal and hospital autopsies.
Over the objection of organized medicine, CMS announced
its Final Rule in September of 2019, which eliminated this last
vestige of the autopsy requirement, as weak as it was, for hospital
participation in Medicare. In their final ruling, CMS commented:
[W]e believe that it is appropriate to remove the dupli-
cative and burdensome requirement that hospitals at-
tempt to secure autopsies for other cases of unusual
deaths or for educational interest. We clarify that re-
moving this requirement would not prohibit hospitals
from performing autopsies and we believe that hospi-
tals will implement their own policies regarding au-
topsies. While we understand the commenter's
concerns regarding the decline in the national autopsy
rate, we disagree that the removal of this specific re-
quirement will cause a measurable decrease in the au-
topsy rate, impact quality of care, or dissuade hospitals
from performing autopsies. ... Although we are finaliz-
ing our proposal, we note that the removal of this re-
quirement should not be construed as a diminution of
our support for hospitals continuing to perform autop-
sies for various purposes, and we encourage hospitals
to establish policies regarding autopsies.
George Lundberg, who once declared war on the nonautopsy,
issued a call to arms in the wake of the 2019 CMS final ruling on
the elimination of the autopsy requirement:
[O]n this issue, [CMS is] wrong. ... Today, the first
day of the rest of our lives, is when our knowledgeable
organizations, especially AMA, College of American
Pathologists, American Society for Clinical Pathology,
United States & Canadian Academy of Pathology,
National Association of Medical Examiners, and As-
sociation of Molecular Pathology, plus the professionals
of CMS, simply must overturn this new rule [CMS
Omnibus Burden Reduction Final Rule].
For various good reasons, the autopsy should be reclaimed as
a physician-based medical service reimbursable by Medicare Part
B, not the least of which is to stem the grave and existential threats
due to the FP workforce pipeline. Paying for autopsies would re-
sult in more hospital autopsies, greater support from departments
of pathology for autopsies, greater exposure of pathology resi-
dents, and more forensic pathologists in the workforce pipeline.
Perhaps, alternatively, both hospital and medicolegal autop-
sies should be paid as a public health service. It is of note in this
regard, that in fiscal year 2018, state spending on public health
was US $11.8 billion; both state and local health departments re-
ceive the majority of their funding from grants provided by the
Prevention and Public Health Fund established under the Afford-
able Care Act.
Regardless of the mechanism of payment and by whom, the
value of the venerable autopsy should be recognized and paid for:
Actually, government, private insurance, and the pub-
lic pay for whatever services that the medical profes-
sion and public demand. The allegation that there is
no money to pay for autopsies is a cop-out. Govern-
ment and private industry respond to public demands.
In a free society, government is still by the consent of
the governed.
1. Mulhausen DB. Report to Congress: Needs Assessment of Forensic
Laboratories and Medical Examiner/Coroner Offices. NIJ, OJP, DOJ. NCJ
253626. Released 12/20/2019. Available at:
2. Scientific Working Group on Medicolegal Death Investigation, Increasing
the Supply of Forensic Pathologists in the United States: A Report and
Recommendations. DOJ. 2012.
3. National Commission on Forensic Science, Increasing the Number,
Retention, and Quality of Board-Certified Forensic Pathologists. DOJ.
Approved 8/11/2015.
4. Medicolegal Death Investigation Working Group. Strengthening the
Medicolegal-Death-Investigation System: Accreditation and Certification,
A Path Forward. OSTP. 2016.
5. Clavert S, Kamp J. Opioid crisis strains medical examiners: offices skip
some autopsies and plead for more funds amid a shortage of pathologists.
Wall Street J. 2017.
6. Elinson Z. States' shortage of forensic pathologists delays autopsies: nation
faces scant supply of medical examiners, particularly in rural areas. Wa ll
Street J. 2015.
pathologists-delays-autopsie s-144468 9715.
7. Keating C. Drug deaths overwhelmmedical Examiner's office:opioid crisis
leads to more autopsies. Taxing Medical Examiner Hartford Courant.
8. Amon R. Summit County medical examiner grappling with staff shortage,
spike in drug deaths. The Beacon journal. 2016, Updated May 2, 2016;
9. Collins KA. The future ofthe forensic pathology workforce. Acad Forensic
Pat hol . 2015; 5(4):526533.
10. Oliver WR. 2019 Salary survey, Part 8 FP autopsy workload, pay per
autopsy Slide 4 NAME-L, Aug 12, 2019.
11. Fowler DR. Letter from the NAME president. Acad Forensic Pathol.2016;
12. 2019 FACTS: Applicants and Matriculants Data. Table A-3. 2019.
Tab l e_ A - 1. p df.
Am J Forensic Med Pathol Volume 00, Number 00, Month 2020 Autopsy as Practice of Medicine
© 2020 Wolters Kluwer Health, Inc. All rights reserved. 5
Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
13. Using MCAT Data in 2019 Medical Student Selection. AAMC.https:// iles/c/2/462316 -mcatguide.pdf.
14. School Directory. LCME webpage (accessed 11/9/2019).
15. Kowarski I. 10 Medical schools with the most applicants. U.S. News &
World Report. 2019;
16. Barzansky B, Etzel SI. Appendix: medical schools in the United States,
2018-2019. JAMA. 2019;322(10):986995.
17. Briskin P. Why we should let more foreign doctors practice in America.
Vo x . 2019.
18. Young A, Chaudhry HJ, Pei Z, et al. FSMB census of licensed
physicians in the United States, 2018, FSMB. J Med Regulation.
publications/2018census.pd f.
19. The Complexitiesof Physician Supply and Demand: Projections from2017
to 2032, 2019 Update. AAMC.
20. Brotherton SE, Etzel SI. Appendix: graduate medical education,
2018-2019. JAMA. 2019;322(10):9961016.
21. S.348 (116th Congress, 20192020). Resident Physician Shortage
Reduction Act of 2019. Introduced by Sen. Robert Menendez [D-NJ]
22. Brotherton, op. cit. 2019. Table 3 . p. 1002.
23. 2018 Annual Report. CAP.
24. Sebring RH. The pathology residency review process. Am J Clin Pathol.
25. Robboy SJ, Weintraub S, Horvath AE, et al; and additional members of
the workforce project work group. Pathologist workforce in the
United States: I. Development of a predictive model to examine
factors influencing supply. Arch Pathol Lab Med. 2013;137(12):
26. Robboy SJ, Gupta S, Crawford JM, et al. The pathologist workforce in the
United States: II. An interactive Modeling tool for Analyzing future
qualitative and quantitative staffing demands for services. Arch Pathol Lab
Med. 2015;139(11): 14131430.
27. Lundberg GD. How many pathologists does the United States need? JAMA
Netw Open. 2019;2(5):e194308.
28. Parry NM. US pathologist supply down relative to diagnostic demands.
Fortschr Med. 2019.
29. Metter DM, Colgan TJ, Leung ST, et al. Trends in the US and Canadian
pathologist workforces from 2007 to 2017. JAMA Netw Open.
30. Brauer DG, Ferguson KJ. The integrated curriculum in medical education:
AMEE guide no. 96. Med Teach. 2016;37:312322.
31. Raphael S, Lingard L. Choosing Pathology: AQualitative Analysis of the
Changing Factors Affecting Medical Career Choice. Medical Science
Educator. 2019;15(2);
32. O'Grady G. Death of the teaching autopsy. BMJ. 2003;327:802804.
33. Hill RB, Anderson RE. The Autopsy Crisis Reexamined: The Case for a
National Autopsy Policy. Milbank Q. 1991;69(1):5178, at pp. 55 & 57.
34. Lundberg GD. Medical students, truth, and autopsies. JAMA . 1983;250( 9):
35. Brotherton, op. cit.2019.Table3.p.998.
36. Strengthening the Medical Examiner-Coroner System Grant Program.
NIJ webpage.
37. Collins, 2015, op. cit.
38. Oliver WR. 2019 Salary survey, Part 1 age & sex Slides #57 NAME-L,
Aug 6, 2019.
39. Sebring, 1983, op. cit., p. 205.
40. Davis GG, Winters GL, Fyfe BS, et al. Report and recommendations of the
Association of Pathology Chairs' autopsy working group. Acad Pathol.
41. Frequently Asked Questions: Anatomic Pathology and Clinical Pathology.
Review Committee for Pathology. ACGME website. https://www.acgme.
42. Knollmann-Ritschel BEC, Regula DP, Borowitz MJ, et al. Pathology
competencies for medical education and educational cases. Acad Pathol.
43. Shojania KG, Burton EC. The vanishing nonforensic autopsy. NEnglJ
Med. 2008;358(9):873875.
44. Sanchez H. Autopsy rate and physician attitudes toward autopsy.
Medscape eMedicine. 2019.
45. Sanchez , 2019, op. cit.
46. Council on Scientific Affairs. Autopsy. a comprehensive review of current
issues. JAMA. 1987;258(3):362369.
47. Roberts WC. The autopsy: its decline and a suggestion for its revival.
NEnglJMed. 1978;299(7):332338.
48. Hill, 1991, op. cit., p. 57.
49. Wood MJ, Guha AK. Declining clinical autopsy rates versus increasing
medicolegal autopsy rates in Halifax, Nova Scotia: why the difference? A
historical perspective. Arch Pathol Lab Med. 2001;125:924930.
50. Hill RB, Anderson RE. The AutopsyMedical Practice and Public Policy.
Stoneham: Butterworth Publishers; 1988.
51. Ibid.
52. Autopsy in the 21
Century: Best Practices and Future Directions. Hooper
JE, Williamson AK, editors. Switzerland: Springer; 2019.
53. Buja LM, Barth RF, Krueger GR, et al. The importance of the autopsy in
medicine: perspectives of pathology colleagues. Acad Path. 2019;6:19.
54. De Cock KM, Zielinski-Gutiérrez E, Lucas SB. Learning from the dead.
NEnglJMed. 2019;381:18891891.
55. Reichert CM, Kelly VL. Prognosis for the autopsy. Health Aff.1985;4(2):
56. Goldman L, Sayson R, Robbins S, et al. The value of the autopsy in three
medical eras. NEnglJMed. 1 983;308(17):10001005.
57. Angrist A. Breaking the postmortem barrier. Bull N Y Acad Med.
58. Bassat Q, Castillo P, Alonso PL, et al. Resuscitating the dying autopsy.
PLoS Med. 2016;1:e1001927.
59. National Academies of Sciences, Engineering, and Medicine. Improving
diagnosis in health care. National Academies Press. 2015.
60. Flexner A. Medical Education in the UnitedStates and Canada: A Report to
the Carnegie Foundation for the Advancement of Teaching. Bulletin no. 4.
1910. Available at
61. Allen M. Postmortem: Death Investigation in America: Without Autopsies,
Hospitals Bury Their Mistakes. Propublica.2011.
62. O'Leary DS. Relating autopsy requirements to the contemporary
accreditation process. Arch Pathol Lab Med. 1996;120(8):763766.
Weedn and Menendez Am J Forensic Med Pathol Volume 00, Number 00, Month 2020 © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
63. Open Forum: A Debate on the Autopsy: Its Quality Control Function in
Medicine. Hum Pathol. 1974;5(5):605613.
64. Porterfield JD. JCAH director discusses new standards. Hospitals.
65. Hoyert DL. The Changing Profile ofAutopsied Deaths in theUnited States,
19722007, NCHS Data Brief, No 67, 2011;
66. Angrist. op cit. 1968, p. 832.
67. Hill. op cit. 1988, p. 71.
68. Reichert. op cit. 1985, p. 88.
69. Rodin AE. Osler's autopsies: their nature and utilization. Med Hist.
70. Friedman E. Public hospitals: doing what everyone wants done but few
others wish to do. JAMA. 1987; 257(11):14371444.
71. Zampieri F, Rizzo S, Thiene G, et al. The clinico-pathological conference,
based upon Giovanni Battista Morgagni's legacy, remains of fundamental
importance even in the era of the vanishing autopsy. Virchows Arch.
72. Lundberg G D. The archives of pathology and l aborator y medicine and the
autopsy. JA MA. 1984;252( 3):390392; at p. 392.
73. Orsini LA. Health insurance and the autopsy. Am J Clin Pathol.
1978;69(2 Suppl):248249.
74. The Henry J. Kaiser Family Foundation. Focus on Health Reform.
National Health Insurance: A Brief History of Reform Efforts in the US.
75. Social Security Amendments of 1965. Pub. L. No. 8997, 1965, currently
codified at 42 U.S.C. § 1395 et seq.
76. Lundberg. op cit. 1984, p. 390.
77. Pontius EE. Financing mechanisms for autopsy. Am J Clin Pathol.
1978;69(2 Suppl):245247.
78. Shapiro MJ. Reimbursement for autopsies. A personal view. Arch Pathol
Lab Med. 1984;108(6):473474.
79. Reichert. op cit.8990.
80. Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. No. 97248,
1982, codified at 42 U.S.C. A41395xx(a)(1).
81. Bierig JR. Spirit of the law: The little-known history of Part A
paymentsand why they belong to you, Mar 2004, CAP Today. http://
82. Liston L. Dispelling the myths: billing for the professional component of
clinical pathology. Lab Med. 2004;35 (3):150151.
83. Lundberg. op cit. 1983, at p. 1199.
84. Bierig. op cit.2004.
85. Shapiro. op cit.1984.
86. Sanchez. op cit. 2019.
87. Personal Communication, Maurine Dennis (CAP) to Stuart M. Graham,
Oct 23, 2019, regarding an inquiry into hospital autopsy compensation.
88. California Code, Government Code - GOV, Art. 2.5 Autopsy,
§ 27522 (added by Stats. 2016, Ch. 787, Sec. 7. (SB 1189) Effective
January 1, 2017).
89. Coroner/Medical Examiner Laws, by State. CDC webpage.https://www.
90. Reichert. op cit. 1985, p. 90.
91. Medicare and Medicaid Programs; Regulatory Provisions to Promote
Program Efficiency, Transparency, and Burden Reduction (Omnibus
Burden Reduction). CMS. 83 FR 47686, 2018, at p. 47736. https://www.
92. Medicare and Medicaid Programs; Regulatory Provisions to Promote
Program Efficiency, Transparency, and Burden Reduction; Fire Safety
Requirements for Certain Dialysis Facilities; Hospital and Critical Access
Hospital (CAH) Changes to Promote Innovation, Flexibility, and
Improvement in Patient Care (Omnibus Burden Reduction Final Rule).
CMS. 84 FR 51732, 2019, at p. 51745.
93. Lundberg. op cit. 1983, p. 1200.
94. Lundberg GD. Hospital of the future: 0% autopsy rate. Med Comment.
95. Johnson SR. Public health funding falls despite increasing threats.
Mod Healthc. 201 9.
96. Lundberg. op cit. 1983, p. 1199.
Am J Forensic Med Pathol Volume 00, Number 00, Month 2020 Autopsy as Practice of Medicine
© 2020 Wolters Kluwer Health, Inc. All rights reserved. 7
Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
... Osteological expertise is critically valuable during recovery of remains to guarantee that small bones and potential evidence are not overlooked. Given the well-documented shortcomings of most coroner systems [10,[14][15][16] and the critical shortage of qualified forensic pathologists [17,18], it is reasonable to assume that many skeletal forensic cases do not receive adequate investigation in both field and laboratory settings. [19]. ...
... While medicolegal skeletal cases are properly and professionally handled in many cities and states across the United States, this is not the case in all states. As anthropologists discuss progressive changes to the discipline, recruitment of new students, and standardizing best practices with published error rates [1], we posit that there should be dialogue about enacting laws to ensure that fo- in the United States [17,18]. Most importantly, engaging qualified experts in any death investigation will refine and influence professional standards and competency nationwide. ...
Full-text available
Human skeletal remains (HSR) are routinely excavated from archeological contexts and analyzed by experts in human osteology. Contrarily, HSR in medicolegal contexts are usually recovered by law enforcement officers and examined by pathologists with limited osteological training. To examine legal requirements for expertise, we reviewed laws in the United States regarding the recovery and analysis of HSR from archeological sites, unmarked graves, and medicolegal contexts. Of the 50 states, 19 (38%) have laws stating that an anthropologist with osteological training should be involved in the recovery or analysis of HSR from an archeological context. Fifteen of those 16 states have laws requiring a minimum level of education to be a qualified skeletal analyst. In contrast, only one state, Texas, requires an anthropologist who handles forensic cases to have a doctoral degree. Including Texas, only eight states (16%) have laws that encourage but do not mandate consultation with a forensic anthropologist for medicolegal skeletal cases. Louisiana and Washington have state-funded laboratories, expert forensic anthropologists, and effective protocols for handling forensic cases. Due process and human rights concerns at stake in criminal cases require that those recovering and analyzing modern HSR have an equal or higher level of expertise than those working with archeological remains. Yet, legislators assume that law enforcement and pathologists are adequately trained. Because court standards demand expert testimony based on accepted methodologies and standard levels of competency, forensic anthropologists have a professional responsibility to engage with lawmakers to draft legislation to ensure proper handling of all skeletal cases.
... The medicolegal death investigation system in the US is grossly underfunded [9][10][11]. This lack of appropriate resources results in numerous negative outcomes, including non-competitive pay [12,13], overwork, burnout [14][15][16], and insufficient time to investigate active and cold cases [17][18][19]. ...
Full-text available
There are 985,026 physicians with Doctor of Medicine (MD) and Doctor of Osteopathic Medicine (DO) degrees licensed to practice medicine in the United States and the District of Columbia, according to physician census data compiled by the Federation of State Medical Boards (FSMB). These qualified physicians graduated from 2,089 medical schools in 167 countries and are available to serve a U.S. national population of 327,167,434. While the percentage of physicians who are international medical graduates have remained relatively stable over the last eight years, the percentage of physicians who are women, possess a DO degree, have three or more licenses, or are graduates of a medical school in the Caribbean have increased by varying degrees during that same period. This report marks the fifth biennial physician census that the FSMB has published, highlighting key characteristics of the nation's available physician workforce, including numbers of licensees by geographic region and state, type of medical degree, location of medical school, age, gender, specialty certification and number of active licenses per physician. The number of licensed physicians in the United States has been growing steadily, due in part to an expansion in the number of medical schools and students during the past two decades, even as concerns of a physician shortage to meet health care demands persist. The average age of licensed physicians continues to increase, and more licensed physicians appear to be specialty certified, though the latter finding may reflect more comprehensive reporting. This census was compiled using the FSMB's Physician Data Center (PDC), which collects, collates and analyzes physician data directly from the nation's state medical and osteopathic boards and is uniquely positioned to provide a comprehensive snapshot of information about licensed physicians. A periodic national census of this type offers useful demographic and licensure information about the available physician workforce that may be useful to policy makers, researchers and related health care organizations to better understand and address the nation's health care needs.
Full-text available
Importance The current state of the US pathologist workforce is uncertain, with deficits forecast over the next 2 decades. Objective To examine the trends in the US pathology workforce from 2007 to 2017. Design, Setting, and Participants A cross-sectional study was conducted comparing the number of US and Canadian physicians from 2007 to 2017 with a focus on pathologists, radiologists, and anesthesiologists. For the United States, the number of physicians was examined at the state population level with a focus on pathologists. New cancer diagnoses per pathologist were compared between the United States and Canada. These data from the American Association of Medical Colleges Center for Workforce Studies’ Physician Specialty Data Books and the Canadian Medical Association Masterfile were analyzed from January 4, 2019, through March 26, 2019. Main Outcomes and Measures Numbers of pathologists were compared with overall physician numbers as well as numbers of radiologists and anesthesiologists in the United States and Canada. Results Between 2007 and 2017, the number of active pathologists in the United States decreased from 15 568 to 12 839 (−17.53%). In contrast, Canadian data showed an increase from 1467 to 1767 pathologists during the same period (+20.45%). When adjusted for each country’s population, the number of pathologists per 100 000 population showed a decline from 5.16 to 3.94 in the United States and an increase from 4.46 to 4.81 in Canada. As a percentage of total US physicians, pathologists have decreased from 2.03% in 2007 to 1.43% in 2017. The distribution of US pathologists varied widely by state; per 100 000 population, Idaho had the fewest (1.37) and the District of Columbia had the most (15.71). When adjusted by new cancer cases per year, the diagnostic workload per US pathologist has risen by 41.73%; during the same period, the Canadian diagnostic workload increased by 7.06%. Conclusions and Relevance The US pathologist workforce decreased in both absolute and population-adjusted numbers from 2007 to 2017. The current trends suggest a shortage of US pathologists.
Full-text available
This article presents a perspective on the importance of the autopsy in medical practice and science based on experiences of the authors as physician-scientists involved in autopsy practice. Our perspectives are presented on the seminal contributions of the autopsy in the areas of cardiovascular disease, including congenital heart disease, atherosclerosis, coronary artery disease, and myocardial infarction, and infectious disease, including tuberculosis and viral infections. On the positive side of the future of the autopsy, we discuss the tremendous opportunities for important research to be done by application of advanced molecular biological techniques to formalin-fixed, paraffin-embedded tissue blocks obtained at autopsy. We also note with concern the countervailing forces impacting the influence of pathology in education and clinical practice at our academic medical centers, which also present impediments to increasing autopsy rates. Our challenge as academic pathologists, whose careers have been molded by involvement in the autopsy, is to counter these trends. The challenges are great but the benefits for medicine and society are enormous.
Full-text available
Autopsy has been a foundation of pathology training for many years, but hospital autopsy rates are notoriously low. At the 2014 meeting of the Association of Pathology Chairs, some pathologists suggested removing autopsy from the training curriculum of pathology residents to provide additional months for training in newer disciplines, such as molecular genetics and informatics. At the same time, the American Board of Pathology received complaints that newly hired pathologists recently certified in anatomic pathology are unable to perform an autopsy when called upon to do so. In response to a call to abolish autopsy from pathology training on the one hand and for more rigorous autopsy training on the other, the Association of Pathology Chairs formed the Autopsy Working Group to examine the role of autopsy in pathology residency training. After 2 years of research and deliberation, the Autopsy Working Group recommends the following:Autopsy should remain a component of anatomic pathology training. A training program must have an autopsy service director with defined responsibilities, including accountability to the program director to record every autopsy performed by every resident. Specific entrustable activities should be defined that a resident must master in order to be deemed competent in autopsy practice, as well as criteria for gaining the trust to perform the tasks without direct supervision. Technical standardization of autopsy performance and reporting must be improved. The current minimum number of 50 autopsies should not be reduced until the changes recommended above have been implemented.
The downward trend in the rate of clinical autopsies has been extensively documented in the literature. This decline is of concern when the benefits of the clinical autopsy are considered. In contrast, the rate of medicolegal autopsies has not been studied in such detail. What little reference there is to medicolegal autopsy rates suggests an absence of the same downward trend. A retrospective review of autopsy data over a 13-year period from the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia, and from the Office of the Chief Medical Examiner of Nova Scotia was conducted. This review showed a difference between the rates of clinical and medicolegal autopsies for the metro Halifax area. The clinical autopsy rate was consistently less than 30% and declined to 15% in 1999, while the medicolegal autopsy rate was consistently greater than 40% and rose to 62% in 1999. The literature proposes many reasons for the decline in the clinical autopsy rate, but none for this difference between rates. The explanation proposed here is the changing and currently uncertain purpose of the clinical autopsy versus the clear, and consistent over time, purpose of the medicolegal autopsy.
Audio Interview Interview with Dr. Kevin De Cock on the research and public health benefits of autopsies and other forms of postmortem investigation. (10:34)Download A striking trend in medical education and practice over the past half century has been the decline in the rate of autopsies conducted throughout much of the world. But there is much we can learn from the dead, for both clinical and public health purposes.
The American Medical Association (AMA) and the Association of American Medical Colleges (AAMC) sponsor and administer the National GME Census through GME Track, an internet-based AAMC product, and jointly maintain a database of information on training programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) and of the residents and fellows in those programs.
Open the PDF file to view the tables for Medical Schools in the United States, 2018-2019.