OCME: Life in America’s Top Forensic Medical Center, New Book by Bruce Goldfarb

Bruce Goldfarb is an award-winning writer whose work has appeared in the Baltimore Sun, Washington Post, USA Today, Baltimore magazine, American Archaeology, American Health, and many other publications. For ten years, Bruce has served as executive assistant to the Chief Medical Examiner for the State of Maryland and the public information office for the Office of Chief Medical Examiner (OCME). Bruce’s newest book, OCME: Life in America’s Top Forensic Medical Center published February 2023.

Host Mike Sacopulos discusses the new OCME book with Goldfarb, a behind-the-scenes portrait of one of the largest and busiest forensic medical centers in the United States. Once celebrated as the gold standard of death investigation, the OCME of Maryland was hammered between an epidemic of violence and opioid deaths and strangling budgetary restraints imposed by indifferent state officials, ultimately plunging the institution into crisis. The author highlights the dedicated professionals who work against increasingly daunting odds.

In the U.S., forensic death investigation is in a precarious state. The shortage of forensic pathologists, shrinking government support, a decade-long opioid epidemic causing a rising tide of drug related deaths, delays in autopsies leading to delayed burial and survivor benefits being paid, delays in criminal investigations and civil litigations, all contribute to a system failing to provide essential public health services in many parts of the country.

This transcript has been edited for clarity and length.

Mike Sacopulos: My guest today is Bruce Goldfarb. For 10 years, Bruce served as executive assistant to the Chief Medical Examiner for the State of Maryland. His new book is, OCME: Life in America's Top Forensic Medical Center.

Bruce Goldfarb, welcome to SoundPractice.

Bruce Goldfarb: Good morning. Thank you for having me.

Sacopulos: Bruce, how did a nice writer like you end up in a place like the Office of the Chief Medical Examiner?

Goldfarb: Well, it was just the way things turned out. I had a background in journalism, but before then I was an emergency medical technician and had been around medicine and healthcare much of my younger life, up until getting my degree at University of Maryland. Then I switched over to journalism. When the opportunity presented itself ... I knew that the OCME of Maryland was a celebrated place. I was uniquely suited for the position, and it was an amazing experience and an extraordinary privilege.

Sacopulos: Please give me a sense of the daily activities of the Office of the Chief Medical Examiner. What are the duties of the office? How many employees are there?

Goldfarb: Well, the OCME of Maryland is a statewide agency. Maryland has a centralized agency, and basically, the Forensic Medical Center of Maryland operates as a hospital for dead people. As you probably know, about 80% of people die in hospitals or nursing homes or hospices. They're known to have some illness and they get progressively worse, then they die. So, the primary care doctor, their attending physician, signs a death certificate. But, about 20% of people die under other circumstances, where they didn't show up for work, they die from injury, or violence, or unknown circumstances. Perhaps they’re just found dead somewhere. Somebody needs to sign that death certificate. You need to actually diagnose that person and determine the cause and manner of death. That’s what the medical examiner does for those unexpected, sudden deaths.

Sacopulos: Your book, and I think it's fair to say, in part, paints a grim portrait of the state of the Office of Chief Medical Examiner. Can you explain some of the problems faced by the office?

Goldfarb: Well, it's not just Maryland. There is a very severe nationwide crisis in forensic medicine and a severe shortage of forensic pathologists. The forensic pathologist typically is in the public sector. They work for governments and so they're not compensated, as well as in the private sector.

In the last few years, we have been through a sentiment of shrinking government, and the public health system, particularly after two years of a pandemic, has really been stretched to its limits. A decade of the opioid epidemic has just caused a rising tide of those drug-related deaths. It's really stressed the system. So, a combination of an increasing caseload, reduced workforce, reduced funding, reduced attention by the public and by government ... and that's under the best of circumstances. Half the country isn't even served by medical examiners, or by well-trained forensic pathologists. There's only about 400, 450 forensic pathologists in the entire country, and the National Association of Medical Examiners estimates that we need, right now, today, 1000 to 1200 just to handle current needs throughout the country.

Sacopulos: It doesn't seem overly dramatic to say that we have a crisis.

Goldfarb: There is a very severe crisis, and autopsies either aren't being done, or they are delayed. The reports are delayed. It may seem like an administrative function to produce an autopsy report, but everything hangs in the balance. Everything is on hold during that time period. So not only is a family grieving, and on tenterhooks waiting for the cause and manner of death, but life insurance benefits don't get paid out, burial benefits, survivor benefits from social security don’t get paid. Criminal investigations, civil litigation investigations by Child Protective Services, there are people who are at risk in these cases. And so, yes, it is a very, very serious crisis throughout the country.

Sacopulos: You mentioned compensation. Are these salaried positions most places, or are examiners ever compensated by the work? By the autopsy?

Goldfarb: I know about Maryland, and many other places, the medical examiners are staff doctors who are salaried professionals. They do hire ... some of the slack is picked up by per diems, who come in and work by the day, from other jurisdictions, and they get paid, I believe by the case. And in places where ... I mentioned about half the country's still in the coroner system.

I was recently in a Midwest state, in a community where the closest forensic pathologist is an eight-hour drive away. So, in those sorts of circumstances, I would imagine, a pathologist would be compensated by per case.

Sacopulos: It is interesting. You're in Maryland, I'm in the State of Indiana. We elect coroners by the county, and there's no requirement that they have any medical training whatsoever. Oftentimes we have people that are funeral directors who are elected County Coroner.

Goldfarb: It's not unique to Indiana. That is actually quite common. There are 13 states that are still strictly on coroners. 23 states have medical examiners, 16 of those are statewide agencies like Maryland. There are 14 states like New York and a few others, where you have both medical examiners and coroners.

Sacopulos: We've talked a little bit about the number of forensic pathologists that are out there, and how many are needed. How long does it take to train someone to be a forensic pathologist? If one wanted to move forward quickly, and put lots of resources into this, it seems to me that there's not a fast solution.

Goldfarb: There is not a fast solution. And that's part of the problem. An MD has had four years of pre-med, four years of medical school, and then they do a residency, which is typically four years in pathology. And then the forensic pathology is a year or two, depending on the person, but it's generally a year for the fellowship in forensic pathology. So that's 13 years. So even if you decided today we're going to turn on the spigot and train many forensic pathologists, they wouldn't be available to work in the market. It would be years down the road.

Sacopulos: Is some work of forensic pathologists done by general pathologists just because of the general need?

Goldfarb: Yes. Not just general pathologists, but in parts of the country, they're not even pathologists. In some states, a medical examiner could be a dentist, a chiropractor, or even a veterinarian. There are EMTs who are doing this work, emergency physicians, and other sub-specialists. Communities have to do what they can with the resources that they have.

Sacopulos: Walk me through an autopsy in general terms. How long does it typically take a forensic pathologist to perform an autopsy, and what findings are needed before a body can be released?

Goldfarb: Well, interestingly, the process at the medical examiner's office is very similar to what we undergo in a checkup – an annual physical examination. The autopsy is a physical examination, a very thorough head to toe examination inside and out. They look externally at the skin for any sort of mark or bruise or a wound, or anything that might be of significance. And everything is photographed and documented. They do the incision, all the organs are visually examined, palpated, weighed, measured. Including the brain. They draw fluids for toxicology. When we go to the doctor for a checkup, they do a urinalysis, do some blood work, and do a chest X-ray. A review of the results. And in an autopsy, it is a similar process.

They'll do the X-rays; they'll do the urinalysis and blood work. For a fairly simple case, it could be two and a half, three hours. On something that's more complex with more complex injuries, because every injury needs to be measured and documented, it could take longer. But once that examination is done, once all of the specimens have been obtained, X-rays have been obtained, all the photographs, the examination is done, that body is ready to go. They can go to the funeral home or crematory, whatever the family wants to do. At the OCME of Maryland, the autopsy was typically within 24 hours or so.

Sacopulos: Is it centralized in Maryland that those bodies are all brought to one location, or did you have representatives of your office throughout the state?

Goldfarb: They have forensic investigators who are trained in each of the counties. Maryland has 23 jurisdictions, so they have trained people in those counties doing field investigation. There's one centralized facility in the state, where all is vertically and tightly integrated. There’s one building where all the autopsies are, they have their own laboratory, they have their own histology, they keep their records there, the training is there, the offices are there. Having all contained in one place, it makes it very easy to supervise.

Sacopulos: As we discuss the problem of demand surpassing supply, if you think about in economic terms, with forensic pathologists and the need for them, I'm wondering is there any technology help here? Is there any kind of way that technology can come to the rescue and speed up the process?

Goldfarb: Like these virtual autopsies? This is not my opinion, it is what I’m hearing from people who are doing the work, that there is no substitute for seeing with your own eyes, there's really still no substitute for a hands-on examination.

I don't think the technology is quite there yet. What they've done in other areas is, they've trained paraprofessionals to do this work. There are graduate programs in forensic medicine. There's one here at the University of Maryland.

One problem, one issue, is that paraprofessionals are not accepted as expert witnesses in court. Judges want a physician, they want somebody who's licensed, someone who is an independent professional. So, there’s that resistance from the courts. And because even if it is a nurse or another professional, they're working under somebody else's license. Further, doctors don’t want paraprofessionals in that role as it’s a threat to their livelihood. So, they're not really enthusiastic about it. I really don't have an answer, but I don’t think it is AI. I don't think it's technology.

Sacopulos: Is there a private option for families willing to pay? If so, it seems to create a dual system of justice, if the forensic backlog is just for poor and middle-class folks?

Goldfarb: Well, a person can hire a pathologist to do an autopsy. The thing is the law in Maryland and these other jurisdictions says that the medical examiner shall do an examination. The medical examiner is vested in that authority to determine the cause and manner of death. So, I don't see how that could be privatized. And even if it were, there aren't the physicians to privatize it. There just aren't any doctors. Typically, these are all government employees who do the forensic autopsy for the purpose of determining the cause and manner of death. So, the authority to do that is put on the medical examiner.

Sacopulos: The epilogue in your book OCME: Life in America's Top Forensic Medical Center, has some heartbreaking stories of children missing parents' funerals because body backlog. Does any state statutorily limit the time a medical examiner can hold a body, or can the office just hold it as long as it needs to?

Goldfarb: I'm not aware of any such laws that do that, that require a medical examiner to release a body. These delays are not uncommon. A cursory Google search will find that there are delays in autopsies, and autopsy reports, in jurisdictions from coast to coast. It's a terrible situation. I mean, there's certain things you can't speed up. At the OCME of Maryland, I don't want to give away book spoilers, but they ended up developing a backlog, and there really isn't much you can do. Once you have that body backlog, I mean, you can't be jumping people ahead of others in the process. So, you have to do it first come first served. I don't know any other way around it. And things take time. There's only so much work one human can do in a day. And so, what do you do?

Sacopulos: So, bodies are handled as they come in? There's no prioritization if there’s a victim of a crime and the goal is to prevent future crime? No prioritization of that type of examination?

Goldfarb: For the most part, the fair thing to do is examinations on a first come first, serve basis. I can’t speak to other jurisdictions and what they do if they prioritize likely homicide cases. In Maryland there have been some high-profile homicide cases, where prioritizing had to be done, like an active investigation and they need the projectile, or a piece of evidence needed for the investigation. That's not fair because there's always going to be an urgent case. If you prioritize the important ones, then the less important ones keep getting pushed back further and further and that's no good.

Sacopulos: Does the delay ever result in the inability to do a full examination? I mean, I'm wondering if bodies degrade while waiting to be autopsied.

Goldfarb: They do and there is decomposition. But they are still able to do an examination. There is information that's lost, obviously because there is decomposition going on, coloration changes. But medical examiners can work with what they have whether someone has just died, or a few days later, or a moderately or severely decomposed or even skeletonized body. So whatever spectrum continuum of decomposition there is, they can still examine what they have. Obviously, you would like to have all when it is new and fresh, when all the information is there rather than the risk of decomposition and have some information lost.

Sacopulos: Is genetic information from bodies collected and uploaded into any database to the best of your knowledge?

Goldfarb: Not in Maryland, not that I'm aware of. DNA is typically used for body identification. And in Maryland, identification is done by the police, not by the medical examiner. And other jurisdictions may do it differently. The OCME of Maryland did not retain anything like that. They retained histology slides, and those sorts of things, which could be used for genetic screening. They keep a blood card for DNA matching. They've been doing that since the early 2000’s for every case they can get blood, but it's not uploaded to any sort of database. They just keep a file drawer with the blood cards, and if a request comes in for paternity testing, they can provide a sample, but there's no genetic data that's retained by the office.

Sacopulos: Does the office ever get requests from researchers for general data? Let's say I'm a researcher and I'm looking at a certain area of biology or medicine, can I ask the Office of Chief Medical Examiner for general data?

Goldfarb: They get many requests. And data are generated, and they're provided to a number of different clients throughout the state. Maryland happens to have a very good data set because it is a statewide agency. And the OCME was established in 1939. So longitudinally from year to year, it's the same people using the same definitions. So, cause and manner of death is defined clearly versus a state where, to pick at random, South Carolina, where they have 100 counties, and each county has three different physicians. Over a period of years, you have 100’s of different doctors who have signed death certificates as medical examiners. The consistency, and how they define things could vary. Maryland has a very, very good data set. And Johns Hopkins School of Public Health has used it extensively for a lot of studies and research and projects. And the Center for Injury Research and Policy at Johns Hopkins was drawn from the OCME data set. There have been major contributions to public health that have come from the cause and manner of death data in Maryland.

Sacopulos: That's fascinating, and something that, I guess, we should view in a very positive sense coming out of the office, right?

Goldfarb: Well, yes. I mean, as an example, Susan Baker who established the center at Johns Hopkins using OCME of Maryland data, she realized that babies have a disproportionate risk of death in car crashes. And it was her research at the OCME of Maryland that led to mandatory safety seats throughout the country. So, that sort of studying the data leads to policies and changes that affect many, many, many people. And countless millions of people's lives have been touched, improved, and saved, because of public health folks at Johns Hopkins using the OCME of Maryland data.

Sacopulos: Bruce, please talk about your book, OCME: Life in America's Top Forensic Medical Center. Who's the book written for? Why should people read it? Give us a little bit of an overview.

Goldfarb: Well, honestly, I had been in journalism for many, many years. And before I started working at the OCME, I only had a vague sense of what a medical examiner does. Like most people, I like the TV shows. Forensic science and true crime are just hugely popular in television and books and podcasts, and you name it. But there's a lot of misconceptions from the TV shows and people. And I would get many questions about what it was like to work there. I wrote about OCME because it is a well-known and the first statewide system, it has this background to it, this history, which is significant.

I wanted to create a portrait and show people what it's like, and to explain the day-to-day, and introduce the people who work there, and what they do, and what the work really involves, and what it's like to work in a forensic medical center. I wanted to demystify forensic medicine, and to shine a light, and explain how things really, really work in a place like that.

Sacopulos: I have to tell you, it's a fascinating read, and I highly recommend it to our audience. My guest has been Bruce Goldfarb. His book is OCME: Life in America's Top Forensic Medical Center. Bruce, thank you so much for being on Sound Practice.

Goldfarb: Thank you for having me.

brucegoldfarb.com/ocme

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