The number of autopsies handled by the Honolulu Department of the Medical Examiner has more than doubled since 2008. That combined with a staffing shortage has meant individual forensic pathologists have had to take on higher-than-average caseloads, and autopsy reports are taking months.

Despite a recent 10.5% salary increase approved for the deputy medical examiner position, the job hasn’t been filled since 2019. The department is also short one additional forensic pathologist. Forensic pathologists and medical examiners perform autopsies and investigate cases, but the chief and deputy medical examiner have additional leadership and administrative duties.

Honolulu Chief Medical Examiner Masahiko Kobayashi warned in a presentation to the Honolulu Salary Commission in January that if the office’s current staff of three goes down to two for any reason, “this department is literally over.”

The Honolulu department isn’t the only one struggling. A nationwide shortage of certified forensic pathologists and an increasing number of autopsy cases, largely due to surging drug overdose deaths, have been overwhelming medical examiner’s offices around the country.

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With only about 1% of medical students nationally go into forensic pathology, experts worry the strain on medical examiner’s offices will continue to grow. The University of Hawaii hasn’t had a forensic pathology graduate in more than five years, said Karen Thompson, chair of pathology at the university’s medical school.

“I think that the specialty itself can be very stressful because you’re dealing with autopsy cases, many of which are unexpected or under violent circumstances,” she said. “And it takes a special person to be able to work under those conditions all the time.”

Nationwide Increase In Autopsies

Deaths are referred to the Department of the Medical Examiner when a person dies by violence, an accident or suicide, as well as in cases involving the sudden death of an apparently healthy person or whenever a death certificate is not signed by the person’s primary care physician, according to Kobayashi. The office also handles the cases of those who die in prison, in a “suspicious or unusual manner” or within 24 hours of admission to a hospital.

In 2008, the department worked on 655 cases. These included cases where no autopsy was performed because only medical records were reviewed or a body was externally examined.

In 2023, that number more than doubled to 1,374.

One reason for the increase is that the state’s aging population has led to more deaths overall. The percentage of people 65 and over in Hawaii grew from 7.9% in 1980 to 19% in 2020. The number of total deaths reported to the Department of the Medical Examiner also more than doubled between 2008 and 2023 from 1,904 to 3,512.

Kobayashi said another factor is that during the Covid-19 pandemic, many people did not receive regular check-ups from their primary care physicians, so there was an increase in deaths deemed “unattended” because their doctors couldn’t sign their death certificates.

Drug overdose deaths have also increased. In 2022, 326 fatal overdoses were reported in the state, compared to just 229 in 2018, according to the Hawaii Department of Health. Autopsies are recommended any time a person is suspected to have died of a drug overdose, according to the National Association of Medical Examiners.

Drug overdoses, particularly those involving opioids and the narcotic fentanyl, are the driving factor straining short-staffed medical examiner’s offices around the country, said John Fudenberg, executive director of the International Association of Coroners and Medical Examiners.

In 2015, about 48,000 drug overdose deaths were reported in the U.S., but that shot up to more than 105,000 in 2023, according to the Centers for Disease Control and Prevention.

In Baltimore, one of the U.S. cities most heavily impacted by the drug crisis, the backlog of bodies became so severe in 2022 that a parking garage had to be converted into a temporary morgue, according to local news station WMAR. The station also reported the state’s Department of Health, which oversees the Office of the Chief Medical Examiner, had a 17.2% vacancy rate at the time.

The San Diego County Medical Examiner’s Office has also been warning that a surge in fentanyl-related overdose deaths has caused autopsy reports to take up to six months to complete, according to the San Diego Tribune. The office’s caseload rose 30% between 2019 and 2021, and as of February 13 of its 77 positions were unfilled.

Where Are The Forensic Pathologists?

Kobayashi said Honolulu is not experiencing a backlog of bodies like some other cities are, but autopsies aren’t always completed as quickly as he would like. Ideally, an autopsy will be performed the business day following a body’s arrival to the morgue, but sometimes it takes two days.

The department has had to rely on the help of per diem doctors, who are not employed by the office but can take cases when they’re available. Staff forensic pathologists have also had to take on greater caseloads.

In 2022, Kobayashi and his department’s two staff forensic pathologists each handled between 414 and 471 cases, not all of which involved autopsies. Per diem doctors took on 57 cases. The National Association of Medical Examiners recommends forensic pathologists perform no more than 250 autopsies per year.

The higher caseload means final case reports take longer, sometimes six months or more depending on the complexity and how much testing needs to be done. Kobayashi said he tries to prioritize cases such as homicides or those in which the family of the deceased needs the death certificate for financial reasons, like getting life insurance payouts.

He said he wants to shorten the turnaround time for reports to two to three months, but for that, he needs more staff.

In a statement approving 10.5% salary raises for both the chief and deputy medical examiner, the Salary Commission cited the city’s inability so far to recruit a deputy medical examiner and the limited pool of candidates to select from.

When the raises kick in July 1, the chief medical examiner will earn $400,000 and the deputy $390,000. Forensic pathologists make between $295,000 and $325,000 based on experience and are also eligible for retention bonuses, according to the department.

While the salaries seem comparable to those of other cities — in San Diego, a deputy medical examiner makes $247,416 to $396,386 and a forensic pathologist makes $253,656 to $282,859 — the high cost of living here can be a deterrent, particularly for candidates with student loan debt, Kobayashi said.

Even though they are some of the highest-paid positions in county government — the mayor, by comparison, makes $209,856 — many medical students interested in pathology choose to go a different route because they can earn even more in the private sector, Fudenberg said. Clinical and anatomic pathologists, who study and diagnose diseases through the analysis of bodily fluids or tissues and often work in hospitals or independent laboratories, can earn between $320,500 and $549,400, according to the Honolulu Salary Commission.

In the years between 2007 and 2013, an average of just 21 people per year finished training and began practicing forensic pathology full-time, according to the National Commission on Forensic Science.

In 2020, there were about 500 practicing board-certified forensic pathologists in the nation, but more than double that number were needed to meet the demand, according to an article in the American Journal of Forensic Medicine and Pathology.

Fudenberg said doing autopsies for a living isn’t “everybody’s cup of tea.” It can also be taxing on a person’s mental health in a field where taking care of one’s mental wellbeing often isn’t prioritized.

“Forensic pathologists see in one day what most people don’t see for their entire life,” he said. “That can be taxing, that can be traumatic, or that can impact the longevity of a career.”

A Vital Career

Kobayashi said a book written by a forensic pathologist he plucked off a shelf while growing up in Tochigi Prefecture north of Tokyo inspired him to pursue a career in the field. He said he loved the way the author described the interesting cases he worked on and how he interacted with the families of the deceased and gave them closure.

There are difficult moments, he said, particularly conducting autopsies on babies or young people. He copes by detaching himself emotionally and throwing his mind into the science. He separates his work life from his personal time, pursuing hobbies like the Japanese martial art of Aikido with his kids.

The job is difficult and at times thankless, but he said it’s fulfilling. He sees his duty as sacred.

“Many people see God’s creation in autopsy,” he said. “The human body is made in such a great way … All the decedents actually teach us how to make diagnoses and how to do our job, so I’m forever grateful for every body I touch.”

Thompson said she hopes schools and universities will be able to recruit more students to the field by introducing medical students to it early on and emphasizing its importance. A bill in Congress, HR8069, introduced this year aims to incentivize students by allocating $13 million to fund forensic pathology fellowship programs around the country. The bill was referred to the Committee on Energy and Commerce in April.

“It’s a fascinating field in many ways,” Thompson said. “It’s vital, both to the closure of families in providing answers to them to what happened to their loved one. … And also this information that they provide from autopsies results in medical, legal evidence that can provide justice to victims and families.”

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This story was originally published by Honolulu Civil Beat and distributed through a partnership with The Associated Press.