Periodically, articles in the forensic pathology literature decry the horrible situation of many coroner and medical examiner systems in this country. In his editorial published in 1994, Dr. James Luke describes “disadvantaged” medical examiner systems—medical examiner offices that are poorly funded or poorly supported by the local government. He advises prospective applicants to the top job in these systems to be wary. “The little voice that whispers, ‘Convince them when you get there,’ does great disservice,” Dr. Luke writes. “Once the position has been accepted, leverage evaporates1.”

Dr. Luke knows very well about what he writes. Many a chief medical examiner has been embarrassed publicly by a very public departure from the job. The media frequently decries the poor state of the office, and blame is readily transferred to the embattled chief. All too frequently, news accounts relate the woes of coroner and medical examiners in trouble throughout this country.

Perhaps the “mother of all” depressing medical examiner articles is one written by the late Dr. Irving Root, a pathologist who worked for the San Bernardino County Coroner in Southern California2. In his opening salvo, Dr. Root writes, “Forensic pathology in the coroner/medical examiner’s system occupies the most unenviable position in American history, American medicine, and American politics, ‘Quincy’ notwithstanding.” Dr. Root describes the forensic pathologist as someone on the horns of a dilemma—a dilemma not of his or her own making but one for which he or she has to accept blame. His description of forensic pathology as a “Catch 22” harkens back to the novel and satire written by Joseph Heller, depicting the predicament brought about by serving in the military in wartime3. Dr. Root saw the forensic pathologist as similarly embattled.

Dr. Root’s article has always interested me because I had the opportunity to train under him. While a pathology resident in the early 1980’s at the Loma Linda University Medical Center in Southern California, I took an elective in forensic pathology at his office for two months. During that elective, I fell in love with forensic pathology. I found what I wanted to do for the rest of my career. When I told Dr. Root that I wanted to become a forensic pathologist, he immediately replied, “Don’t go into forensic pathology!”

Taken aback, I asked, “Why not?”

His reply to me was direct. Forensic pathologists work for a government. Governments are run by politicians who sense that the public is not interested in dead people and high quality death investigation. Inevitably, these politicians cut the death investigation budget, figuring that there are other more worthwhile ways to spend public money. When the budget is cut, the forensic pathologist makes due with less by cutting corners and by trying to do more with fewer resources. Eventually in this environment, the forensic pathologist makes a mistake. This mistake is amplified by an unsympathetic news media. The forensic pathologist is publicly humiliated. After all, he or she is a doctor, and the doctor is never allowed to make a mistake. Politicians are allowed to compromise, according to Dr. Root, but a doctor is never allowed to compromise. The doctor is “morally, ethically and legally obligated to provide care at the highest possible professional standard2,” but the governmental agency that employs the doctor insists that he or she work in a compromised situation.

Dr. Root presented a compelling argument for not becoming a forensic pathologist. After all, with all the opportunities made possible by a medical degree, why would anyone willingly put him or herself into this unenviable situation?

Recently, prior to entering private practice in forensic pathology, I completed 11 ½ successful years as a chief medical examiner. During my tenure in Kansas City, Missouri, I have learned that forensic pathology is not a Catch 22. It is just the opposite. As forensic pathologists, we have an opportunity to effect important change in a vitally important area of society. Excellent, highly professional death investigation is possible. Armed with some knowledge, one can turn around even the most disadvantaged of coroner and medical examiner systems.

How do I know this? Because I did it!

During those 11 ½ years, I took a highly flawed and “disadvantaged” medical examiner system and led the way to making it a tremendous success. In 1995, I accepted to head an office with one broken autopsy table and shared office space. In 2006, I left the office in a 10,000 square foot modern, state-of-the-art facility. In 1995, I accepted to head an office with a reputation for scandal and incompetence. By 2006, the office had been accredited twice by the National Association of Medical Examiners and had an accredited forensic pathology fellowship training program. During my time as a chief medical examiner, I learned important and vital lessons that, if put into practice, will lead to professional success, not only for the forensic pathologist but also for the system he or she serves, no matter how troubled it is. With the proper approach, I believe success is inevitable!

This manuscript presents the 22 lessons I learned after 11 ½ years as a chief medical examiner. I present it with the hope that “disadvantaged” death investigation systems will become things of the past! I present it with the hope that we will train a generation of forensic pathologists to become effective leaders and managers.

1 Luke JL: “Disadvantaged” Medical Examiner Systems. Some Thoughts on Maintaining Standards Worthy of the Public We Serve. Am J Forensic Med Pathol 15(2): 93-94, 1994.

2 Root I: “Forensic Pathology – Catch 22. A No-Win Situation (?). Am J Forensic Med Pathol 7(3): 237-240, 1986.

3 Heller J. Catch-22. New York: Simon & Schuster, 1989.