Forensic pathology

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The heart of a murder victim

Forensic pathology is a job of forensics. It is pathology that focuses on determining the cause of death by examining a corpse. The post mortem is performed by a medical examiner, usually during the investigation of criminal law cases and civil law cases in some jurisdictions. Coroners and medical examiners are also frequently asked to confirm the identity of a corpse. Also see forensic medicine.

Scope of forensic pathology

Forensic pathology is an application of medical jurisprudence. The forensic pathologist:

• Is a medical doctor who has completed training in anatomical pathology and who has subsequently specialized in forensic pathology. The requirements for becoming a "fully qualified" forensic pathologist vary from country to country. Some of the different requirements are discussed below.
• Performs autopsies/postmortem examinations to determine the cause of death. The autopsy report contains an opinion about :
  • The pathologic process, injury, or disease that directly results in or initiates a series of events that lead to a person's death (also called mechanism of death), such as a bullet wound to the head, exsanguination caused by a stab wound, manual or ligature strangulation, myocardial infarction resulting from coronary artery disease, etc.), and
  • The "manner of death", the circumstances surrounding the cause of death, which in most jurisdictions include:^[1]
    • Homicide
    • Accidental
    • Natural
    • Undetermined
• The autopsy also provides an opportunity for other issues raised by the death to be addressed, such as the collection of trace evidence or determining the identity of the deceased.
• Examines and documents wounds and injuries, both at autopsy and occasionally in a clinical setting.
• Collects and examines tissue specimens under the microscope (histology) in order to identify the presence or absence of natural disease and other microscopic findings such as asbestos bodies in the lungs or gunpowder particles around a gunshot wound.
• Collects and interprets toxicological analyses on body tissues and fluids to determine the chemical cause of accidental overdoses or deliberate poisonings.
• Forensic pathologists also work closely with the medico-legal authority for the area concerned with the investigation of sudden and unexpected deaths i.e. the coroner (England and Wales), procurator fiscal (Scotland) or coroner or medical examiner (United States).
• Serves as an expert witness in courts of law testifying in civil or criminal law cases.

In an autopsy, he/she is often assisted by an autopsy/mortuary technician (sometimes called a diener in the USA).

Forensic physicians, sometimes referred to as 'forensic medical examiners' or 'police surgeons' (in the UK until recently), are medical doctors trained in the examination of, and provision of medical treatment to, living victims of assault (including sexual assault) and those individuals who find themselves in police custody. Many forensic physicians in the UK practise clinical forensic medicine part-time, whilst they also practice family medicine, or another medical specialty.

In the United Kingdom, Membership of the Royal College of Pathologists is not a prerequisite of appointment as a Coroner's Medical Expert, i.e. doctors in the UK that are not forensic pathologists or pathologists are allowed to perform medicolegal autopsies, simply because of the vague wording of 'The Coroners Act', which merely stipulates a 'suitably qualified medical practitioner', i.e. anyone on the GMC Register.

Investigation of death

Deaths where there is a known cause and those considered unnatural are investigated. In most jurisdictions this is done by a "forensic pathologist", coroner, medical examiner, or hybrid medical examiner-coroner offices.

Terminology is not consistent across jurisdictions

In some jurisdictions, the title of "Medical Examiner" is used by a non-physician, elected official involved in medicolegal death investigation. In others, the law requires the medical examiner to be a physician, pathologist, or forensic pathologist.

Similarly, the title "coroner" is applied to both physicians and non-physicians. Historically, coroners were not all physicians (most often serving primarily as the town mortician). However, in some jurisdictions the title of "Coroner" is exclusively used by physicians.

Canadian coroners

In Canada, there is a mix of coroner and medical examiner systems, depending on the province or territory. In Ontario, coroners are licensed physicians, usually but not exclusively family physicians. In Quebec, there is a mix of medical and non-medical coroners, whereas in British Columbia, there is predominantly a non-physician coroner system. Alberta and Nova Scotia are examples of ME systems ^[2][3]

Coroners and medical examiners in the United States

In the United States, a coroner is typically an elected public official in a particular geographic jurisdiction who investigates and certifies deaths. The vast majority of coroners lack a Doctor of Medicine degree and the amount of medical training that they have received is highly variable, depending on their profession (e.g. law enforcement, judges, funeral directors, emergency medical technicians, nurses).

In contrast, a medical examiner is typically a physician who holds the degree of Doctor of Medicine or Doctor of Osteopathic Medicine. Ideally, a medical examiner has completed both a pathology residency and a fellowship in forensic pathology. In some jurisdictions, a medical examiner must be both a doctor and a lawyer, with additional training in forensic pathology.

History

In German-speaking Europe, lectures on forensic pathology were regularly held in Freiburg in the mid 18th century and Vienna in 1804. Scientists like Auguste Ambroise Tardieu, Johann Ludwig Casper and Carl Liman made great effort to develop forensic pathology into a science based on empirics.

Forensic pathology was first recognized in the United States by the American Board of Pathology in 1959.^[4]

In Canada, it was formally recognized in 2003,^[5][6] and a formal training program (a fellowship) is currently being established under the auspices of the Royal College of Physicians and Surgeons of Canada.^[7]

Education

In most English speaking countries, forensic pathology is a subspecialty of anatomical pathology. Training requirements differ from country to country.

Australia

There are currently three paths to qualify as a forensic pathologist in Australia. The first is to train solely in forensic pathology (although a significant amount of anatomical pathology knowledge is still required) and pass two examinations for forensic pathology only. The second is to commence training in anatomical pathology, and complete an initial anatomical pathology examination, which takes a minimum of three years; then go on to train solely in forensic pathology and complete a forensic pathology examination, which takes a minimum of two years. The third is to complete a minimum 5 years' training in anatomical pathology to qualify as a fellow in anatomical pathology, then complete a post-fellowship year in forensic pathology (a minimum twelve months further training plus successful completion of an examination).^[8]

Canada

In Canada,^[9] anatomical pathology is a five-year residency. Residents who wish to become forensic pathologists must then complete a one-year fellowship in forensic pathology. Forensic pathology is a sub-specialty by the Royal College of Physicians and Surgeons. Two schools that have training programs are the University of Toronto and Mcmaster University.

India

In India, the speciality is commonly referred to as Forensic Medicine and Toxicology or Legal Medicine. After completion of medical graduation (MBBS), one has to complete three years of study and training including thesis research, which leads to award of degree of MD (Forensic Medicine). One can also alternately pass the board examination conducted by National Board of Examinations, leading to awarding of Diplomate of National Board (DNB).

The majority of the specialists are attached to the Department of Forensic Medicine and Toxicology in various medical colleges. The classification of posts includes Assistant Professor (Lecturer), Associate Professor (Reader) and Professor. The work profile of the specialists includes conducting autopsies and clinical forensic examinations; apart from teaching the medical students. They have to regularly appear in the courts as expert witnesses. A typical department in a government institution conducts 100 to 5000 autopsies a year depending upon the jurisdiction. Apart from this the clinical forensic examinations constitute a major part of the work and number of cases can run up to 10000 a year in an average institution.

The largest association of the specialty is Indian Academy of Forensic Medicine (IAFM), which also publishes its quarterly Journal of Indian Academy of Forensic Medicine regularly. This association has a specialist member strength of more than 1000.

Indonesia

In Indonesia, forensic medicine, also known as legal medicine ("kedokteran kehakiman"), is a 3-year specialty program that can be taken directly after completing medical school. It is separate from anatomical pathology and clinical pathology. Upon completion of the program, a forensic medicine specialist will obtain the title Spesialis Forensik, or Sp.F. He or she may be addressed in public as Dokter Forensik ("forensic doctor"). Note that there is no pre-medicine program, making the total duration of formal education for one to become a forensic specialist 8 years.

Forensic medicine is also a mandatory round during medical school clerkship. Medical students assist the doctors on autopsies, and they may also be allowed to perform an autopsy under supervision, and to witness in the court.

United Kingdom

In the UK, anatomical pathology is a five-year residency. Successful candidates are eligible for inclusion on the specialist register of the General Medical Council (GMC) having obtained Membership of the Royal College of Pathologists (United Kingdom).

A specialist training (ST) post is applied for after the foundation year to enter a training program in Histopathology. Imminent changes as a result of the Tooke report may require two years or more to be fulfilled on general rotational placements before the option of histopathology arises. However, the Royal College have not yet issued their response to this matter. It is then necessary to obtain the MRCPath Part I examination in Histopathology, after which it is then possible to apply to one of few training posts in Forensic Pathology in the UK. Current approved centres include Belfast, Liverpool, Leicester, Cardiff, London, Sheffield, Glasgow and Dundee. Not all the posts are currently actively training. Following 3 years training in Forensic Pathology and completion of the FRCPath Part II slanted to Forensic Pathology you may then obtain CCT (certificate of completion of training) and work as a Consultant Forensic Pathologist. Another option is to obtain the full FRCPath in general histopathology, followed by another 18–24 months of training in forensic pathology, which will qualify the candidates with either the Diploma of the Royal College of Pathologists in Forensic Pathology (DipRCPath (forensic)), or the Diploma in Medical Jurisprudence (DMJ). In England & Wales you will also need to be Home Office Accredited, which will require checks of your training portfolio and completion of a security check and the Expert Witness Training Course run by the Forensic Science Service.

Foreign graduates and specialists need to apply to the GMC and the RCPath directly to practise Forensic Pathology in the United Kingdom.

United States

In the United States, forensic pathologists typically complete at least one year of additional training (a fellowship) after completing an anatomical pathology residency and having passed the "board" examination administered by The American Board of Pathology or The American Osteopathic Board of Pathology ("board-certified"). Becoming an anatomic pathologist in the United States requires completing a residency in anatomic pathology, which is on-the-job training one must perform upon completing medical school before one may practice unsupervised. Anatomic pathology (as it is called) by itself is a three-year residency. Most U.S. pathologists complete a combined residency in both anatomic and clinical pathology, which requires a total of four years.

In the United States, all told, the education after high school is typically 13–15 years in duration (4 years undergraduate training + 4 years medical school + 4–5 years residency [anatomic and clinical pathology combined] + 1-2 year forensic pathology fellowship). Generally, the biggest hurdle is gaining admission to medical school, although the pass rate for anatomic and forensic pathology board examinations (in the U.S.) is approximately 80-90 and 90-100 percent, respectively. The courts do not require American Board of Pathology certification in order for a witness to be qualified as an expert in the field of forensic pathology, and there are several "diploma mills" that give online certificates in the field.^[10]

See also

• Forensic science
• Post-mortem chemistry

Notes and references

Further reading

• Bartos, Leah, "No Forensic Background? No Problem", ProPublica, April 17, 2012.
• Burton, Julian N.; Rutty, Guy N. (eds.) (2010). The Hospital Autopsy: A Manual of Fundamental Autopsy Practice (3rd ed.). London: Hodder Arnold. ISBN 978-0-340-96514-6. OCLC 653083337. 
• Gorea, R. K.; Dogra, T. D.; Aggarwal, A. D. (2010). Practical Aspects of Forensic Medicine A Manual for Undergraduates and General Practitioners. New Delhi: Jaypee Brothers Medical Publishers. ISBN 978-81-8448-994-1. OCLC 729254521. 
• Payne-James, Jason (ed.; et al.) (2005). Encyclopedia of Forensic & Legal Medicine. Amsterdam; Boston: Elsevier Academic Press. ISBN 0-12-547970-0. OCLC 60834620. 
• Payne-James, Jason; Busuttil, Anthony; Smock, William S. (eds.) (2003). Forensic Medicine: Clinical and Pathological Aspects. London; San Francisco: Greenwich Medical Media. ISBN 1-84110-026-9. OCLC 51678652. 
• Saukko, Pekka J.; Knight, Bernard (2004). Knight's Forensic Pathology (3rd ed.). London: Edward Arnold (Publishers). ISBN 0-340-76044-3. OCLC 56440239. 
• Spitz, Werner U.; Spitz, Daniel J. (eds.) (2006). Spitz and Fisher's Medicolegal Investigation of Death: Guidelines for the Application of Pathology to Crime Investigation (4th ed.). Springfield, Ill.: Charles C. Thomas Publisher. ISBN 0-398-07544-1. OCLC 56614481. 
• "The Real CSI, PBS Frontline documentary, April 17, 2012.

External links

• National Association of Medical Examiners (NAME)
• American Academy of Forensic Sciences
• Forensic Science Society
• British Association in Forensic Medicine
• British Association for Human Identification
• British Academy of Forensic Science
• Forensic Medicine for Medical Students - a website providing educational resources in forensic medicine
• Faculty of Forensic & Legal Medicine of the Royal College of Physicians
• Royal College of Pathologists of Australasia
• Forensic Oral Pathology Journal - FOPJ
• Punjab Academy of Forensic Medicine & Toxicology
• 2011 books for forensic pathology.
• Indian Congress of Forensic Medicine and Toxicology

Becoming a pathologist

• A career in forensic pathology - educational website on career pathways for forensic pathology in the UK and USA
• So, you want to be a forensic scientist? - Simon Fraser University.
• When I grow up: becoming a pathologist by G. William Moore, MD, PhD. - netautopsy.org.
• What is a Pathologist? - a perspective from UK pathologist Fraser Charlton.
• Forensic Pathology Resource
• Royal College of Pathologists of Australasia - Follow the "Careers and Training" Link, & go to "Disciplines and Career Brochures", or go to this page directly
• Royal College of Pathologists UK
• Forensic Pathology by David Webb, University of Huddersfield
• Forensic Pathology Pathway in Residency and fellowship - USMLE Forums