Discussion in 'Pharmacy Residencies and Fellowships' started by mustang sally, Nov 29, 2014
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Which specialty is best suited to your interests, abilities, and personality?
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Discussion in 'Pathology' started by nraesmith, 04.26.12.
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Well, for what it's worth, I was interested in forensics until I experienced decomposed bodies. There's something about a putrid, dead body whose skin and hair sloughs off in your gloves as you remove it's clothes that I just couldn't get over... not to mention the maggots that crawl out of their nose and exist as flies for the next week in the morgue.
Ask your school if there is a FP rotation or a rotation with a Medical Examiner you may take. If so, I would think that would let you know, or at least give you a better perspective, if you could handle it. It never hurts to ask.
Understandable, my thinking was that some will not be bothered by while other are. Some may get use to it, where others can never get use to it. Just hard to say and will vary greatly person to person.
Agree with the others that you need to do a rotation at your local ME's office to see if you can handle the decomps. Unless you're in the deep south, make sure you do it between April and October; decomps are a different flavor (more mummified, less icky) in winter up north.
I'm an FP and decomps are gross - there's no way to sugar coat it. But it's part of the job, so you need to be able to handle it. Doing a half-arse job and missing a homicide because you don't like being around a decomp isn't acceptable; thus you have to be able to spend 3 hours on a decomp case moving aside maggots and looking for injury (actually, maggots help you find injury, as they preferentially are deposited on exposed flesh).
There's going to be major bias in these answers. Those of us doing FP obviously learn to deal with it, while those that are too grossed out won't pick FP. Put it this way; I've not known anyone who really, really loved FP but was so put off by decomps that they picked another area of pathology. I'm sure such people are out there, but they're not the majority. Those that like FP do it and deal with all it entails, and those that don't like the work contribute to the field of pathology in the diagnostic fields. Probably much more of an issue in the decision making process is the pay differential between FP and diagnostic path, but that's another thread for another day.
Mint oil and an N95 mask will cover the vast majority of the odor. The issue of rotting tissue falling apart in your hands still persists, though.
None of us can adequately explain the experience of performing an autopsy on a decomposed body. You need to see it for yourself.
They're not too common, but you will see them in general forensic practice. Our program which is located in a rural area with many more bodies found in out in nature or forgotten about in abandoned trailers than homicides, gets probably 15-20 nasty decomps out of 600 or so autopsies per year.
Where I'm training, I'd estimate (very rough guess, just off the top of my head), that about 5-8% of cases are decomps, varying stages, from mild skin slippage, bloating, and some marbling, to the really bad ones with maggot infestation and post-mortem animal scavening activity.
I'll also add I'm not a fan of the mask or mint oil. Doesn't work for me. I prefer to just go in, get a big whiff and overhwelm the olfactory sensors, and then it's tolerable for me. But I think I'm in the minority, as most of our tech and faculty do mask up when they take decomps.
In my experience as a boarded FP ( not currently practicing) the decomps are indeed tough. but FORGET the scents, and oils and incense and masks. If you go in and do it, you will be inured to it in about 5 minutes. it's like walking into a john that smells heavily of s***. after a few minutes you don't nearly notice it as much. the worst thing you can do is come in, then out, etc because you never maintain your acclimated tolerance. the menthol stuff just makes a bad decomp a bad menthol decomp.
Another vote for getting exposure. I'm a first year path resident and was fairly sure (but not 100%) that I was going to be going into forensics, but I too wondered about the decomp thing. I did my ME rotation and saw as many decomps as I could to see if I could handle it. It was pretty smelly, but it didn't affect me too much, so now I'm set on FP.
Nice to hear. If you have any questions along the way, feel free to PM me.
I too am very interested in path and fp. During college i was lucky enough to earn beer money by working as an autopsy tech at our coroner/crime lab 2-3 days a week. I actually had a strong vasovagal to the first autopsy (not even a decomp) but I sat down and forced myself to get through the next one. After 3 years they never let me live that down! Decomps weren't too awful, I hated the burns, too messy and disturbing that my stomach growled. Sorry to hijack, but is the market for fp much better than other areas? I think it is my # one choice, but I have enjoyed pm&r alot as well, if market is pretty open for fp, I think I would trade the extra 70k to get back to the aitopsy suite. Any guidence from those ahead of me?
not sure what you mean by open, but the general belief is that there are nowhere near enough FPs to do the work that needs to be done, and i've not heard of a competent fellow being unable to find a job. but you will not be able to choose/guarantee what part of the country you'll live in.
I guess by "open" I mean could find a job out of fellowship without applying to 20 positions. I dont have any geographic preferences, and actually like the midwest. I know of the 3 fellows I worked with, one was hired in house, one went to a different city in-state, and the one I knew best always said the market was tough. However it was his 3rd fellowship and he ended up outside of fp, so maybe he never really wanted fp.
Based on my experience, I'd answer your question as "yes". I don't know of any FP fellows in recent years from where I'm training that wanted a job in FP, were willing to move anywhere in the US (or Canada ), yet couldn't find a job. There are two main website where FP jobs are posted (AAFS and NAME, but NAME's job postings requires one to be a NAME member I believe, which most FPs are). That said, plenty of jobs are filled without every being posted. The community is small enough that many jobs are filled via word of mouth and phone calls.
Decomp: Like anything, you generally get used to it. I totally agree that once you're in it, stay until you're done. However, I think observers have it harder than those actually doing the case, because observers don't have as much to think about or do except to work themselves up about how much it stinks and how much X looks like bad stew, or whatever. The people (med students & residents) I've known who said it was just too much were generally those who were never interested in forensic path in the first place, or had many reasons other than just decomp for going down another career path (the impression and the reality of what forensic path entails ain't always the same, decomp or no). A lot of people fear decomp and grossness and getting emotionally scarred, and I do have the impression that the level of said fear correlates with their ability to cope when actually faced with it -- but I don't know which is more causative, the fear or the actual situations/grossnesses.
Incidentally, about 49 of my last 715 cases (autopsy + external only, but we do relatively few externals; currently doing about 250 autopsies per year) were decomps (tagged as bloating or advanced decomp), NOT including early decomp which was another ~55 (just a little skin slippage, out of rigor, a little organ softening, relatively minor smell, etc.), and not including those I tagged as skeletons, which generally don't have a grossness/smell problem. I also work in a generally hot and humid climate with lots of waterways (=floaters=often decomp). YMMV.
Job market: My impression remains that the FP market is better than other pathology specialties, but it's true that one must be willing to move, and one must realize that changing jobs will essentially require moving again since MEO's tend to cover large areas. Jobs are out there now for finishing fellows, and there are way, way, way too few FP's to properly cover the country as-is -- however many areas intentionally do not spend money to recruit an FP or run a real office, or have been pressed into undercoverage by the economy, all of which is a slowly evolving issue. It's also worth reminding the medical students that you'll have to get through 3-4 years of general pathology residency with probably only 1 or 2 of months of forensic pathology, and another few months (2~4 or so) of hospital autopsy, while the rest of your residency will be spent doing primarily other things -- it's not just finish med school and go straight into forensic training, even in the rare dual AP/FP pre-tracked programs.
I might have posted here more accurately a few years ago, but when I was applying for jobs I made contact with...half a dozen or so places, maybe? I got the impression I could have interviewed at any of them, but I was selective about who I told I was interested in enough to visit, particularly after getting quick interview offers at preferred offices, and I interviewed at..er..at least 4 places I recall (two formally affiliated with a med school path department, with the chair involved in contract negotiations), and politely turned the others down. Every place I interviewed I think had formally posted a job, though I touched based with a couple or so others I had heard about to get some information on what they had available, salary, office details, etc. One place was pretty aggressive in recruiting, offering some contract alternatives, etc., to try to work something out, and one place chose someone else during the process, neither of which affected where I most wanted to go (after interviewing, etc.) and which is where I ended up. Again, YMMV.
i would second all of KC's comments and they have been valid for more than 25 years. one of my motivations for a forensic fellowship was the security/fall-back position the subspeciality offered in ambiguous times and it is still valid. also, in some jurisdictions you can bill for your professional time at trial which is a significant hit. there are are all sorts of arrangments but something like $350/hr with a minimum of 2 hours to include travel, prep, wait, etc and $300/hr for all subsequent time has been accepted in places i have seen. of course you will pay self employment tax on it. you need professional guidance to set it up to look professional, formal and in compliance. but there is some money there.
i have seen defense lawyers bitch that they are entitled to "confront all witnesses: as a constitutional right" and that is fine. but the second they ask me an "opinion" i become an expert witness and the clock ticks. if the want to keep me in the former catagory, the questions will be ---did you do---?----when did you do? the second it becomes what did you determine----expert testimony.
I too must agree with all that has been said above. Best way to find out is by getting exposure to FP by doing a rotation at the ME's office. I am about to start my residency in pathology and am set on specializing in FP. I was able to do an internship at my local ME's office while in undergrad...in the summer...in FL...and at first was nervous for the whole autopsy experience. But as soon as I experienced my first autopsy I was hooked! Of course, then came my first decomp, and again, I wasn't sure how I'd react, but what helped was that I went to the scene with the medical investigator and then did the autopsy the next day with the ME. I agree, best way is to just go into the suite, let the nose acclimate and don't move around or leave until the end. Decomps are not fun, and even the experienced FPs I worked with never fully get use to it. It's just part of the job, and you just have to do it. I'm looking forward to residency and eventually one day being an FP
What do you mean, "non-forensics cases"? If he's an FP doing cases, they're all forensic. Does he mean non-homicides?
Oh, OK. That is a legit answer, but I'll reply by saying there's a massive difference between medical and forensic autopsies. Different in the approach, goals, expectations, patient populations, diseases seen, etc. If that's the best you can do, take it, but do so knowing the kind of autopsies you will see are not the everyday practice of FPs. Yes, we do some medical-type autopsies (and they actually are some of the more interesting cases sometimes), but the bread and butter of FP is violent deaths, drug and alcohol related deaths, and natural disease in the relatively young without a physician to certify the death.
Unrelated but still forensics-oriented question that I realized I didn't know the answer to: how are true forensic autopsies (as opposed to privately-contracted autopsies) paid for? Is there any sort of medical insurance reimbursement scheme or is it all from the state/county/city budget?
Far as I know, in every US (and I think Canadian as well) jurisdiction, money comes from the government (what level of government is highly variable state to state). I've never heard of a forensic autopsy being paid for by an insurance company. One thing FPs often think about is "how should we be spending the taxpayer's dollars?" that's why we often discuss, within our community, when is it appropriate to do histology, run toxicology, do a complete vs partial autopsy, do an autopsy at all, or even bring a case in for an examination (versus a "scene inspection", as most offices pay for body transport themselves). all of these budget issues relate to the fact that the dollars we spend are those of Mr John Q Taxpayer. spending those dollars irresponsibly is a good way for a chief to get fired. for that reason IHC is rarely done in the forensic setting (we do the best we can on H&E for incidental tumors or even disseminated ones that are the cause of death - vital statistics wants to know benign or malignant and site of origin, if you can figure that out). i could go on for a while - the money aspect of FP is really interesting to me. feel free to PM with any additional questions, and i'll answer best i can based on my limited experience thus far.
The finances of FP is interesting and sometimes frustrating. On the one hand the "government" (taxes) ultimately contributes the vast majority of budgetary money for the vast majority of ME/coroner offices. Health or life insurance monies play no role that I have ever seen. They want the autopsy results as much or more than anyone else, of course, but they certainly don't pay for them. Most laypeople still seem to figure the government can pay for whatever and it's not a big deal, and most laypeople (sometimes including attorneys and law enforcement) have fairly high expectations from an autopsy. But on the other hand, the chief ME/coroner is generally given only a limited budget, and like other people in charge of money...if they can't stay under budget then they don't keep their jobs very long. So, yeah, it's a constant battle to meet the needs and expectations of law enforcement, attorneys, families, community, and relevant statutes, while staying under budget or developing very compelling reasons why you need more money.
Those "other" ways for an office to obtain funding are pretty varied, but some offices can charge for cremation or shipment out of state approvals, some obtain regular grants (a few are fairly easy to obtain but may have to be used for specific pre-approved things, and are usually small amounts), a few I've heard have their FP's contractually obligated to testify on civil cases or even office consult cases and their expert witness fees go to the office (most seem to be contractually obligated to only testify in criminal cases, while civil deposition/testimony or consult cases they privately charge for), others may contract with a hospital system or pathology office to handle their autopsies, etc.
The whole 'defendant must be able to confront all witnesses against them' thing is another matter -- and it's not a small one. For many years the status quo around the U.S. seems to have been that if the FP who did the case was not available, then another FP could and would testify in their stead; the defense might complain (though often did not, I guess), but the judge could allow it anyway. In a very few cases this was understandably avoided. An FP who had retired or lived in a distant part of the country/overseas was not generally expected to return, though almost all are willing to if the side calling them pays for it. Unfortunately some recent court decisions is putting not just trials at risk but also FP's by basically saying that if the FP isn't available (including being dead), then nobody for the prosecution can testify about the autopsy. A lot of this was initially related to requiring the specific lab tech who performed a specific test having to be the one to testify about it (at least as logistically problematic as getting an FP on hand). But, I'm not a lawyer so I don't know the nuances, if there are any. Only that it's a growing and evolving issue.
KC is talking about the Melendez-Diaz decision, as it's known in the legal world. KC and I both have heard (probably from some of the same people) how big a deal this is becoming in the FP world. This legal aspect of medicine is something fairly unique to FP, and to me and most of us in the field, it's sort of fun. What other board exam would have stuff on voir dire or rules of evidence? An FP with unlimited time would be well-served to get a JD - there are a few such folks out there.
Something I've not heard tested yet is the notion of having both a fellow and attending be REQUIRED to testify in the same case. In general, that's a horrible idea, but I wonder if the Melendez-Diaz ruling would allow for such a thing if a defense attorney decide to see if by having both the fellow and attending testify they could find a small inconsistency and raise some "reasonable doubts".
Those are the kinds of things that I suspect will only be tested/exploited if it's really key to the case. Juries are obviously a bit unpredictable, but most are smart enough to know when one side or the other is playing games and can get irritated with them, perhaps even assuming they don't have much of a case if they're focusing just on hassling people. That is, if the jury even sees the wrangling, much of which takes place between just attorneys & judge. But any given issue only has to be challenged and a decision made once for it to abruptly begin affecting every other case...even when the subsequent cases have little to do with whatever that point was. One of the quirks of our system. Anyway.. it's interesting at times, yes, but also a bit like bloatware, such that after time the system bogs down or gets lost in all the excess and loses track of what's important right in front of it.
As for requiring fellows + their attendings, well, again, I suspect that issue will come up but only in very select cases. Those are the same cases that techs and transport personnel and so on all also get subpoena'd -- which happens enough even on routine cases, although they rarely get deposed and more rarely actually have to testify in court. As far as I know (which isn't much) the person whose name is on the autopsy report is the one subpoena'd and expected to testify. In some offices both the fellow & the attending's names are on the reports, but I don't think that's universal; basically, as long as the attending can say they were present for the autopsy and responsible for the opinions in the report, etc., then I don't see that a fellow would be mandated if the defense wanted them. But, who knows. I've heard that in some offices the ex-fellow gets called a lot to testify on their former cases, while in other offices they never do -- my assumption has been that has a lot to do with the name on the report, plus perhaps the local attorney/MEO culture.
Give it a little more time if you think you like the work. You do eventually get used to it (not the decomp, but the regular smell).
See? N95 mask and mint oil, seriously. Don't be a hero.
It's true. We do often wonder if someone's gonna fall out or not. We also like to see how newbies handle decomp. And I do tell everyone who comes in to view their first autopsy that it's better to 'sit' on the dirty floor than it is to pass out face first on it. I've had a lot of complainers and a few who got woozy and left, but I don't recall anyone hitting the deck. Last time I remember that happening was during a comparative anatomy class in college when the professor was showing us how to dissect a dogfish shark. Very slimy innards.
I've occasionally wondered if we get interested in those sorts of reactions because it's a reminder that we see/do some crazy things as compared to the general populace. But I do think that you get used to/numbed to the worst parts of it, although that doesn't always mean you stop -noticing- it (that goes not just for smells, but one's physical and psychological reaction to all the different things one sees, does, and experiences in the job). I've actually started to notice less personal tolerance to decomps if I'm not doing autopsies that day, but if it's my case I tune it out pretty well.
Not to be pedantic or "tough" but if forensics is a SERIOUS career potential choice for you you must forget the "bystander" mask and mint.
I always wondered about this as well. Does examination of the organs serve a function in this case?
I'll try and answer this. If it's a suicide, not really to be honest. You're not doing anything to ansewer cause or manner of death by examining the torso, and for that reason not all offices do full autopsy in cases of suicidal GSWs to the head. The main reason to do it would be to answer potential questions from the family about other diseases the decedent did or did not have.
However if it's a homicide, it's a totally different issue. Someone may get charged with a crime, and you have to be able to answer any questions a defense attorney may ask. To do a partial autopsy on a homicide is gross FP negligence. Attorney could ask, "how do you know the decedent didn't die of a rupture aortic aneurysm instead of the GSW to the head that passed through the frontal lobes without hitting deep cerebral nuclei or the brainstem?" You can come up with other what-ifs, but this issue is non-negotiable. If a case is even the slightest chance of being a homicide, it warrants a full autopsy in every office in the US, unless there are some really unusual circumstances.
As to the issue about treatment of the organs, what you see as "butchering" is a pathologist examining the tissue. The person is dead. What does it matter if you drop a kidney into the organ bucket versus gently placing it down? The goal is to examine things systematically and efficiently - carefully dissecting out the inferior mesenteric artery serves what purpose? Taking 10 minutes to dissect the ever bit of diaphragm off the liver does what? You don't sound unappreciative, but you do sound ignorant about the job FPs do. Part of what comes with experience is knowing what's important in a given case, and tailoring one's dissection to that. If I have a case of witnessed collapse after 2 days of chest pain, I'm not going to worry about a detailed layered anterior neck dissection. But if I have a 29 year old woman found dead with her panties around her ankles, then I'm going to do a very careful neck dissection to rule in or out injury. Do I really need a precise weight on that woman's adrenal glands?
Posting this kind of stuff on an internet forum is fine, but don't talk like this to a practicing FP unless you're ready to get reamed out.
Also, mikesheree is right - I've never seen an FP wearing a mask with mint oil in a decomp case, even the pretty little female FPs. It's part of the job, and if you can't take it, FP isn't for you.
So if I were shot in the head, but on autopsy I also had a ruptured aortic aneurysm, the guy who shot me would get off? That doesn't seem right. Maybe being shot in the head spiked my bp and led to the rupture. Is this example based on a real case?
No, at least not a case I've heard of. And this was intentionally an extreme example. But remember the way the legal system works in this country - "reasonable doubt." Attorneys go for anything they can to introduce that, and all it takes is one juror to think that maybe the guy died because of something else, and you have to do a complete autopsy to answer that question. A more likely scenario would be a blunt force homicide in an older person with co-morbidities.
I don't know if my example would lead to an acquital, but it certainly might. A ruptured AAA with 3L blood in the abdomen is absolutely fatal, while plenty of people do survive, at least for a short time, a single GSW to the head if it doesn't pass through the brainstem.
"Other" autopsy findings also go towards pain & suffering, and related issues that come up in the sentencing phase -- which can make a difference in someone getting 25 yrs, life without parole, or death. That's not to say that some lay coroners out there don't just go "yep, some holes there, gonna be a homicide, you can cremate 'em now." I don't know anyone who would seriously consider not doing an autopsy on an apparent homicide or other truly "suspicious" death (of course, what is suspicious to one person isn't always to another). Well, except Obama. But I certainly know offices that don't autopsy every apparent suicide that comes through (mainly GSW or hangings), or only do a focused dissection of a GSW tract and collect the projectile -- those *tend* to be relatively overworked/underfunded/understaffed offices with hundreds of homicides to deal with annually, but still. Some states/local laws "require" an autopsy on apparent suicides, because of the fear they may be concealed homicides. I've both seen and heard of a number of those (I can't think of anyone in practice more than a few years who claims they haven't, either), and although most are fairly obvious or raise significant suspicions on a good external examination it's generally best practice to do them as an autopsy up front.
You can never be too careful in forensics and you must always assume that the most innocuous case will be afforded great attention at some time when you do not anticipate it. i refer you to Dr. Alan Moritz's classic paper in am j clin path from 1956 (Google it). he was a founder of modern forensic path in the usa and it is titled "classic mistakes in forensic pathology" it is as true today as ever.
What is this in reference to?
Are a lot of D.O's in this field? I got my major in Forensic Chemistry and I have always been fascinated with Forensics
Similar ratio as in other areas of pathology I think, which is to say a few, but obviously a minority.
bin Laden, who was reportedly dumped in the ocean rather than examined. Basically, the equivalent of a lay coroner doing something no-one with forensic pathology training would seriously contemplate, and the sort of -concept- the federally funded NAS report on the forensic sciences (forensic pathology included) was against. And not entirely unlike the Kennedy problem, either; the entertainment industry (movies, media/conspiracy hype, etc.) would -probably- be worse off had Dr. Rose of the MEO in Dallas been allowed to take jurisdiction of the body for an autopsy by someone with forensic training (which legally he probably had, as evidently no federal law existed to supercede Texas law in that matter) as he attempted to do, but was run over by the SS/military, who I guess thought they were doing the right thing by instead taking him across country to a non-forensic pathologist. At least -that- debacle resulted in some very specific plans if anything like it occurs in the future.
I have been shadowing a FP as well, I am slowly getting used to it. The first autopsy I saw this huge pool of blood started forming inside the opened up chest and I got woozy and wanted to vomit all over the place. The smell wasn't too bad until they cut open the intestine and the fecal matter began to pour out.
yes DOs can easily become fp's
I wouldn't say there are a "lot" of DO's in FP, but I agree it's not really a particular barrier as compared to another pathology subspecialty or even most other specialties. Certainly there are a few programs in any given specialty that might turn their noses up at a DO, but that's their problem. In general though, pathology programs and FP fellowships are less concerned with what your letters are than whether you've passed the relevant exams and have both a real knowledge of (as from prior rotations) and an actual interest in the field. A person is pretty useless regardless of their background if they turn out to dislike what they're doing, and while everyone THINKS they know about pathology or FP, very few actually do -- including some med school professors.
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