The New England Journal of Medicine shines spotlight on forensic pathology

Forensic pathologists play a unique role in monitoring and responding to public health threats and advancing our understanding of human disease and injury, according to a new review article published July 3 in The New England Journal of Medicine.

Recognizing that there is little understanding about this key medical subspecialty among the public and even among physicians, the journal asked several forensic pathology leaders to write an overarching review of the field.

“Many people may picture forensic pathology as forbidding and dark, focused on death and criminal investigation the way it’s portrayed on popular television shows like Bones and CSI,” said Rebecca Folkerth, MD, Principal Core Scientist with the Neuropathology Brain Bank and faculty member of the Brain Injury Research Center at Mount Sinai. Dr. Folkerth is also a former neuropathologist for the New York City chief medical examiner and lead author of the review.

“While that is part of our role, the scope of forensic pathology goes far beyond autopsy examinations,” Dr. Folkerth continued. “In addition to performing the final diagnostic evaluation of a person who has died, forensic pathologists play a unique role in monitoring and responding to a myriad of public health threats. We are dedicated to implementing extensive laboratory analyses in order to provide answers for families at times of loss and fear, supplying objective facts for use in the justice system, contributing to public health vital statistics, and assisting in research that advances our understanding of human disease and injury.”

Forensic pathologists are physicians who undergo extensive postdoctoral training. In the United States, forensic pathologists are certified by the American Board of Pathology after completing at least three years of training and examination in an accredited anatomical pathology program or combined anatomical and clinical pathology program (such as the one offered at the Icahn School of Medicine at Mount Sinai), followed by one year of training in forensic pathology. Only 50 forensic pathology training programs, including the program at the New York City Office of the Chief Medical Examiner, are recognized by the Accreditation Council for Graduate Medical Education.

Importantly, forensic pathologists operate completely separately from law enforcement and the courts, and are therefore able to remain independent and objective. They are the last physician to see a person who has died, often unexpectedly or violently, to perform the final diagnostic evaluation and determination of the cause of death. They provide much-needed support to those grieving the loss of a loved one, may direct interested family members to follow-up care for themselves in the event that their loved one died of a heritable disease that might place them at risk for sudden death or illness, and can refer families to research centers for donation of their loved one’s tissues for medical research.

Researchers at Mount Sinai’s Traumatic Brain Injury Research Center are conducting the Late Effects of TBI (LETBI) study to identify the clinical and neuropathological signatures of post-traumatic neurodegeneration, and have collaborated with the New York chief medical examiner’s office for many years. Their work focuses on the long-term effects of traumatic brain injury and how in some people, brain trauma may trigger a cascade of events that lead to neurodegeneration, including Alzheimer’s disease.

“We aim to develop tests (biomarkers) that can be done in living people with traumatic brain injury to help monitor and prevent negative long-term effects,” said Kristen Dams-O’Connor, PhD, Director of the Brain Injury Research Center of Mount Sinai. “To detect these biomarkers, which are based on cell and tissue changes in brain tissue following trauma, we need to look directly at the human brain postmortem at autopsy. Our forensic pathology colleagues are essential and valued partners in achieving this goal, as they often are the ones to see individuals who have passed away from a TBI and who meet with families to discuss the findings. For those families who donate their loved ones’ brain tissue, there is a commitment to furthering scientific research and, often, a desire to understand what their loved one was experiencing towards the end of their life. Forensic pathologists provide that important bridge between the family and the science.”

Forensic pathologists also contribute to accurate public health vital statistics, which are required for the tracking of disease and the allocation of government funds. They work mostly behind the scenes to help manage mass catastrophes related to weather, terrorism, or infectious disease, for the protection of the public’s health. For example, during the COVID-19 pandemic, forensic offices, such as the New York chief medical examiner’s, functioned as disaster mortuaries when local hospitals, nursing homes, and funeral directors became overwhelmed by COVID-19 deaths. Without the expertise of forensic pathologists in management of rapid increases in fatalities, burdens to affected families would have been unthinkably worse.

Study authors note that the field of forensic pathology has a workforce shortage and express hope that better understanding of their role may encourage young physicians in training to consider it as a rewarding subspecialty choice.

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