Grim cri­sis for pathol­o­gists

Fa­tal over­doses leave med­i­cal ex­am­iner’s of­fice strug­gling with work­load

Baltimore Sun Sunday - - FRONT PAGE - By Mered­ith Cohn

The opi­oid epi­demic that has claimed so many lives in Mary­land is over­whelm­ing the state med­i­cal ex­am­iner’s of­fice.

The agency has ex­ceeded na­tional caseload stan­dards — the num­ber of au­top­sies a sin­gle pathol­o­gist should per­form in a year — in each of the past four years. The of­fice now risks los­ing its ac­cred­i­ta­tion.

“Ev­ery­one con­tin­ues to add on work hours and work faster and hope­fully not take short­cuts,” said Dr. David R. Fowler, Mary­land’s chief med­i­cal ex­am­iner. “They ab­sorb this ex­tra load. But there is a point where they can’t con­tinue to add to that and ex­pect the sys­tem will func­tion.”

The chal­lenge is not lim­ited to Mary­land. The com­bi­na­tion of ad­di­tional and more com­plex cases is over­whelm­ing med­i­cal ex­am­in­ers’ of­fices across the coun­try, par­tic­u­larly along the East Coast, leav­ing many on the verge of los­ing ac­cred­i­ta­tion.

“We view this as a na­tional cri­sis,” said Dr. Brian L. Peter­son, pres­i­dent of the Na­tional As­so­ci­a­tion of Med­i­cal Ex­am­in­ers.

The as­so­ci­a­tion cat­e­go­rizes the Mary­land Of­fice of the Chief Med­i­cal Ex­am­iner, tra­di­tion­ally well re­garded by peers, as “de­fi­cient.” It will re-eval­u­ate the Bal­ti­more-based agency in May.

The of­fice can con­tinue to op­er­ate with­out ac­cred­i­ta­tion. But the as­so­ci­a­tion warns that per­form­ing too many au­top­sies can jeop­ar­dize qual­ity and un­der­mine con­fi­dence in the re­sults.

The sit­u­a­tion has trou­bling im­pli­ca­tions for the crim­i­nal jus­tice and pub­lic health sys­tems. Pros­e­cu­tors rely on au­topsy find­ings and med­i­cal ex­am­in­ers’ tes­ti­mony to bol­ster their cases, and pub­lic health of­fi­cials use data from the agency to di­rect re­sources.

State pathol­o­gists are per­form­ing about 40 per­cent more au­top­sies than in 2010 — al­most 100 more each — and the tox­i­col­ogy lab now runs nearly non­stop, of­fi­cials say. But the

of­fice has not sig­nif­i­cantly boosted the ranks of ex­am­in­ers, and is strug­gling to hold on to sup­port staff.

“Mary­land is cur­rently fully ac­cred­ited,” Peter­son said. “But as is the case with many of­fices, it might be fac­ing loss of that ac­cred­i­ta­tion due to the in­ter­sec­tion of caseload and staffing level.”

The agency is part of the state De­part­ment of Health and Men­tal Hy­giene. Med­i­cal ex­am­in­ers in­ves­ti­gate deaths caused by in­jury, homi­cide or sui­cide, and those that are un­timely, sus­pi­cious or not at­tended by a physi­cian. In Mary­land, that’s about a third of all deaths. The of­fice han­dled 14,385 cases in fis­cal year 2016, and per­formed 5,439 au­top­sies.

The of­fice be­gan ex­ceed­ing the na­tional stan­dard of 250 au­top­sies per ex­am­iner per year in fis­cal 2013, ac­cord­ing to the state health de­part­ment. Its in­abil­ity to meet that stan­dard has led to its des­ig­na­tion as de­fi­cient.

Af­ter the first quar­ter of fis­cal 2017, the pathol­o­gists were on tar­get to per­form 328 au­top­sies — ex­ceed­ing the limit of 325 for main­tain­ing ac­cred­i­ta­tion.

Bal­ti­more County State’s At­tor­ney Scott Shel­len­berger, pres­i­dent of the Mary­land State’s At­tor­neys’ As­so­ci­a­tion, said a loss of ac­cred­i­ta­tion would have an im­me­di­ate ef­fect on his cases. Pros­e­cu­tors rely on med­i­cal ex­am­in­ers to pro­vide solid au­top­sies and come to trial pre­pared to tes­tify.

“In some cases there is a height­ened need for foren­sic ev­i­dence to shed light on what ac­tu­ally hap­pened,” he said. “You want that to be the easy part of the case, the least chal­lenge­able and con­tro­ver­sial. If they lose ac­cred­i­ta­tion, it could cre­ate some doubt.”

Dr. Leana Wen, the Bal­ti­more health com­mis­sioner, said she re­lies on in­for­ma­tion from the med­i­cal ex­am­iner’s of­fice to de­velop pol­icy and di­rect re­sources. But it isn’t al­ways avail­able in a timely man­ner.

She noted, for ex­am­ple, that 2016 over­dose death to­tals are not yet avail­able from the state health de­part­ment more than three months af­ter the end of the year.

She said she has turned to hos­pi­tal emergency rooms and emergency ser­vice providers for im­me­di­ate in­for­ma­tion on “hot spots” of sus­pected fen­tanyl over­doses so of­fi­cials can warn peo­ple in the com­mu­nity.

“Con­sid­er­ing the num­ber of over­doses, de­lays make sense in the med­i­cal ex­am­iner’s of­fice,” she said. “But it also can im­pede our work.”

Fowler lists 17 med­i­cal ex­am­in­ers on staff, up from 15 in 2015. He said six more ex­am­in­ers were needed to meet the stan­dards. He re­quested three in the most re­cent state bud­get, out of con­sid­er­a­tion of the costs, about $171,000 each. He did not get them.

He re­ported that the of­fice is com­plet­ing only about three-quar­ters of the au­top­sies in 60 days. The stan­dards call for 90 per­cent to be com­pleted in that time.

In an in­ter­view, Fowler said the sit­u­a­tion stings, even though he knows many other of­fices na­tion­ally face the same prob­lems.

He said of­fices in some other states have racked up back­logs and scaled back ser­vices. He said that won’t hap­pen in Mary­land.

Fowler’s of­fice was con­sid­ered de­fi­cient once be­fore, be­cause it lacked proper space be­fore a new build­ing opened in 2010. That rat­ing was not based on per­for­mance.

Fowler said over­loaded work­ers are more likely to make mis­takes. De­lays mean fam­i­lies wait longer for an­swers and to claim the bod­ies of loved ones.

The state bud­get for fis­cal 2018, which be­gins in July, does not in­clude fund­ing for more ex­am­in­ers. In­stead, of­fi­cials added $400,000 to boost salaries for ex­am­in­ers now work­ing longer hours be­cause they do not earn over­time.

The agency is also be­ing per­mit­ted to fill five open sup­port po­si­tions.

A health de­part­ment spokesman said in­creas­ing salaries was the pri­or­ity this year. Spokesman Christo­pher Gar­rett said of­fi­cials are still ex­plor­ing ways to shift more per­son­nel to the agency.

A spokes­woman for Gov. Larry Ho­gan noted that the bud­get for the med­i­cal ex­am­iner’s of­fice has in­creased from $11.4 mil­lion in fis­cal 2015 to $12.8 in the com­ing year.

“Fund­ing for the Of­fice of the Chief Med­i­cal Ex­am­iner has in­creased each year since the gover­nor took of­fice,” spokes­woman Amelia Chasse said. “The [health] sec­re­tary is cur­rently con­duct­ing an anal­y­sis of the of­fice to de­ter­mine ad­di­tional per­son­nel needs, and our ad­min­is­tra­tion is com­mit­ted to meet­ing those needs.”

Fowler said the of­fice is han­dling a range of new cases, in­clud­ing those from the spike in homi­cides in Bal­ti­more. The city has recorded more than 300 killings in each of the past two years, the first and sec­ond dead­li­est on record.

But there were far more deaths from over­dose: 1,468 statewide in the first nine months of 2016, up from 1,259 for all of 2015, and more than twice as many as in 2010. Mary­land was one of 30 states to re­port a large in­crease in over­dose deaths.

More than 900 of the fa­tal over­doses in 2016 were re­lated to heroin. More than 700 were re­lated to fen­tanyl, a far more pow­er­ful opi­oid that is of­ten mixed with heroin, un­be­knownst to users.

Dr. Bruce Gold­berger, a pro­fes­sor of tox­i­col­ogy at the Univer­sity of Florida Col­lege of Medicine, said fen­tanyl has proved to be the great­est chal­lenge for med­i­cal ex­am­in­ers. Il­licit labs are con­stantly churn­ing out new for­mu­la­tions, he said, and there are not al­ways good test­ing meth­ods to iden­tify them.

Gold­berger, a con­sul­tant for the U.S. Cen­ters for Dis­ease Con­trol and Preven­tion, has stud­ied the ef­fects of fen­tanyl on med­i­cal ex­am­iner of­fices.

He called the com­bi­na­tion of ex­tra cases and more com­plex cases “un­prece­dented.”

“These new emerg­ing drugs, specif­i­cally fen­tanyl analogs, have a cat­a­strophic ef­fect,” Gold­berger said.

His lab per­forms tox­i­col­ogy test­ing for sev­eral Florida county med­i­cal ex­am­in­ers. He said he has seen a surge in re­quests.

“We are in­un­dated,” he said, “and we don’t know how to dig out of it.”

Fowler said he’s still hop­ing for more ex­am­in­ers. He said his staff is ex­tremely ded­i­cated, and of­ten works long hours with­out breaks. But many will qual­ify for re­tire­ment in the next five or six years.

Re­plac­ing them might not be easy, even with fund­ing. The num­ber of prac­tic­ing pathol­o­gists who work as med­i­cal ex­am­in­ers dropped more than 11 per­cent from 2010 to 2015, ac­cord­ing to the As­so­ci­a­tion of Amer­i­can Med­i­cal Col­leges. That was a steeper drop than in any other spe­cialty.

Dr. Janis Or­lowski is the group’s chief health care of­fi­cer.

“I think peo­ple go to med­i­cal school and then choose a spe­cialty based on life­style as much as they choose based on what’s in­ter­est­ing to them,” she said. “Per­haps they see peo­ple in this area are over­worked, as they likely are in the of­fice in Bal­ti­more.”

LLOYD FOX/BAL­TI­MORE SUN 2013

Pathol­o­gists with the state med­i­cal ex­am­iner’s of­fice are per­form­ing about 40 per­cent more au­top­sies than they did in 2010. Over­doses ac­count for much of that in­crease. CASELOAD PER MED­I­CAL EX­AM­INER 2017: 328* *2017 pro-rated based on first quar­ter

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