Background and Overview

The authorized staffing for the Pathology Section includes five authorized Forensic Pathologist positions and three authorized Forensic Autopsy Technicians, for a total of eight authorized positions. It should be noted that the Chief Medical Examiner, although a licensed physician and Board certified in forensic pathology, is not included in this amount because, based on our discussions with Pathology staff, the Chief Medical Examiner does not, as a general rule, perform autopsies on a daily or weekly basis.

The annual salaries and authorized staffing levels for the Pathology Section, as reflected in the FY 1996-97 Annual Salary Ordinance, are as follows:

Of the five authorized Forensic Pathologist positions, one position had been temporarily transferred (TXed) to an 1842 Management Assistant position in order to provide additional administrative support. However, the 1842 Management Assistant positions is currently vacant. In addition, a second Forensic Pathologist position recently became vacant due to a resignation. As such, there are currently three filled Forensic Pathologist positions and three filled Forensic Autopsy Technician positions, for a total of six filled positions in Pathology.

The annual budget for the Pathology Section of the Medical Services Division, as estimated by the Budget Analyst, is approximately $905,550 (see Section IV: Planning and Budget). This consists of (a) $852,043 in funding for permanent and temporary salaries, holiday pay, premium pay and fringe benefits; and (b) $53,507 for non-personnel costs such as materials and supplies, hazardous materials disposal, telephone and other expenses.

Staff Qualifications

The Budget Analyst"s Office has identified two issues related to the qualifications of Pathology staff: (a) two of the three Forensic Pathologists currently employed by the Medical Examiner do not meet the minimum qualifications for their classification; and (b) the current staff of Forensic Autopsy Technicians are not being utilized to their potential, given their extensive backgrounds in forensic sciences and/or medicine.

Forensic Pathologists

The Forensic Pathologist is responsible for performing forensic examinations, dictating medical findings, preparing case reports and presenting interpretations and facts pertaining to the manner and cause of death. According to the licensure requirements contained in the Civil Service Commission"s position description, a Forensic Pathologist is required to be licensed as a physician and surgeon by the State of California and to be Board certified or Board eligible in the field of forensic pathology.

From interviews with staff and a review of staff resumes, we learned that two of the three full-time Forensic Pathologists currently employed by the Medical Examiner are neither Board certified nor Board eligible, and therefore do not meet the minimum qualifications for a Forensic Pathologist. Nevertheless, these two employees are conducting autopsies and making determinations as to the cause and manner of death, which often are used as evidence in criminal proceedings, without proper supervision by the Chief Medical Examiner.

The Chief Medical Examiner should make greater efforts to verify the licensure, certifications and references of applicants for the Forensic Pathologist position or work with Human Resources to rewrite the position descriptions and qualifications for Pathologists. In addition, these two employees should be immediately reclassified by the Human Resources Department to the appropriate classification which is consistent with their qualifications. Reclassification to the 2230 Physician Specialist, a classification for which the two full-time Pathologists meet the minimum qualifications, would result in an annual savings of $136,012 (salary and fringe benefit costs for two 2582 Forensic Pathologists of $323,142 per year, less the salary and fringe benefit costs for two 2230 Physician Specialists of $187,130 per year).

However, it should be noted that these savings would not be attained immediately. The individuals currently holding these positions would be reclassified, and in accordance with personnel policies, maintain their current salaries. At such time as these individuals vacate their positions, the new employees would be hired at the new classification and the reduced rate of pay.

Forensic Autopsy Technicians

According to the Civil Service Commission position description, Forensic Autopsy Technicians are responsible for assisting the Forensic Pathologists in performing autopsies, collecting evidence for testing, and maintaining the morgue premises. The minimum qualifications include a high school diploma and one year of experience (a) in a mortuary facility assisting in the care and handling of bodies or (b) as an embalmer"s assistant.

Two of the three Forensic Autopsy Technicians currently employed by the Medical Examiner are medical doctors with foreign licensure. Nevertheless, their duties are primarily comprised of processing and transporting evidence for testing; preparing and cleaning the autopsy facility; ordering and stocking supplies; and managing the inventory of bodies stored in the morgue. While these tasks are essential to the operation of the Medical Examiner"s Office, our interviews with Pathology staff and our review of practices in other jurisdictions have suggested that the Forensic Autopsy Technicians, given their medical training and experience, could be utilized to a greater degree in assisting in the performance of autopsies. Providing assistance in conducting autopsies under the supervision of a forensic pathologist, is already part of their job description.

As such, we recommend that the Chief Medical Examiner establish a detailed written protocol for Forensic Autopsy Technicians which takes into account the medical backgrounds and/or forensic experience of the Forensic Autopsy Technicians currently employed by the Medical Examiner"s Office. As a result, Forensic Autopsy Technicians would be of greater assistance to Forensic Pathologists in performing autopsies and other procedures, thereby improving the efficiency of operations.

Training

In a 1990 review of the Medical Examiner"s Office conducted by the Office of the Chief Administrative Officer (CAO), the CAO made several observations related to training of Medical Examiner"s Office staff. Two observations were made regarding the training of Pathology staff: (1) staff had not received on-going in-service training related to forensic investigation, examination and autopsy; and (2) the Chief Medical Examiner was the only staff member trained in the use of x-ray equipment, forcing Pathologists to wait until the Chief Medical Examiner was available when x-rays were needed as part of the autopsy procedure.

Through interviews with Pathology staff, we have learned that the Forensic Pathologists still receive no in-service training. In addition, the Chief Medical Examiner spends very little time supervising autopsies, and, as noted earlier, does not perform autopsies on a daily or even weekly basis. Moreover, the Chief Medical Examiner and one other employee are the only employees fully trained in the use of x-ray equipment. As such, our management audit of the Medical Examiner"s Office has revealed that the CAO"s two recommendations related to the training of Pathology staff have yet to be implemented, six years after the CAO"s study was conducted.

We therefore recommend that the Chief Medical Examiner (1) develop and implement an in-service training program for Forensic Pathology staff and (2) provide training to Forensic Pathology staff in the use of x-ray equipment. The Chief Medical Examiner should report back to the Board of Supervisors within six months of the issuance of this report in order update the Board of Supervisors on the Medical Examiner"s progress in implementing these two recommendations.

Forensic Examination Procedures

Another observation made by the Budget Analyst"s Office during the course of this audit is the absence of a comprehensive procedural manual for Pathology staff. Although a procedural manual for pathology does exist, it does not contain a protocol for performing full autopsies versus other types of procedures, a detailed description of the steps involved in performing an external or internal forensic examination, or special procedures such as completing special SIDS protocols, or the policy of photographing all motor vehicle accident cases. As the performance of autopsies is the primary function of the Pathology Section, and given the extremely technical nature of and the attention to detail required in order to perform an autopsy to the standards set by the Chief Medical Examiner, the development of such a procedure manual is essential.

The Pathology Section is responsible for performing both internal and external forensic examinations of bodies in order to determine the cause and manner of death. An external examination is the least invasive procedure used to determine the cause and manner of death and is performed on patients with good medical history and no evidence of trauma or foul play. In such cases, a reasonable but not necessarily exact cause of death is usually apparent from the clinical history. At the other extreme is a full autopsy, which involves the removal of sections of organs and body fluid samples for further pathological and toxicological testing. Full autopsies are generally performed on suspected homicides, motor vehicle accidents and suspicious or unnatural deaths. In the San Francisco Medical Examiner" Office, the decision of whether to perform a full autopsy or an external examination is the Chief Medical Examiner"s, except on weekends, when the Forensic Pathologist on duty makes this determination.

In some jurisdictions, other procedures, such as sign-outs and partial or limited autopsies, are also conducted under certain circumstances. Sign-outs involve the signing of death certificates for Medical Examiner cases by a Pathologist based solely on the medical history of the decedent and involve no examination of the body whatsoever. According to the Chief Medical Examiner for San Francisco, sign-outs are not performed in San Francisco, and all bodies under the jurisdiction of the Medical Examiner"s Office are examined by Pathology staff. Partial autopsies are limited to a particular region or organ system of the body and are usually focused on answering a very specific question regarding the manner of death. Although other jurisdictions and Pathologists distinguish partial autopsies from external examinations, the San Francisco Chief Medical Examiner considers external examinations to be more or less the same as partial autopsies, as external examinations sometimes involve some dissection.

In response to a 1992 survey conducted by the San Mateo County Coroner/Public Administrator"s Office, the San Francisco Medical Examiner"s Office reported that full autopsies were conducted on 84 percent of Medical Examiner cases per year.

We conducted a survey of nine other Medical Examiners, both in California and nationwide, which can be considered somewhat comparable to San Francisco. [1] In this survey, we retrieved statistical data, as well as information on organization, investigations, pathology and toxicology. Table VII.1.1 below shows the percentage of annual deaths over which the Medical Examiner assumes jurisdiction and the percentage of such cases which receive a full autopsy in each jurisdiction surveyed, as compared to San Francisco.

Table VII.1.1

Percentage of Deaths under ME Jurisdiction and
Percentage of Such Cases Which Receive Full Autopsy, by Jurisdiction

As illustrated by Table VII.1.1 above, The percentage of deaths which become Medical Examiner cases in San Francisco is near the median for the nine other jurisdictions surveyed (Median = 20%). However, the number of full autopsies conducted as a percentage of caseload is 84 percent in San Francisco, versus the median of only 44 percent. The reason for this higher percentage of full autopsies in San Francisco could be attributed to several factors.

For example, of the San Francisco Medical Examiner"s cases, there may be a relatively higher proportion of suicides, homicides and accidents, as opposed to natural deaths, which would tend to result in a relatively higher number of full autopsies being conducted in comparison to other jurisdictions.

Other possible and more likely reasons for the higher number of full autopsies in San Francisco could be that (a) San Francisco has sufficient staff available to perform this more extensive and costly procedure (see Staffing Levels below); (b) clear definitions for each type of procedure utilized by the Medical Examiner, and a written protocol for determining when each procedure should be used, do not exist; and (c) the Chief Medical Examiner"s preference for full autopsies. As a result, more full autopsies are being performed than may be warranted.

One potential means of reducing the number of full autopsies conducted is to establish clear, written definitions and criteria for the use of various forensic examination procedures in the San Francisco Medical Examiner"s Office. For example, one possibility would be to define specifically the circumstances under which a full autopsy must always be conducted, and if none of these criteria are met, Pathologists would have the discretion to perform alternative procedures, such as partial autopsies, external examinations or sign-outs. Expanding the opportunities for performing alternative procedures could result in a reduction in the number of more expensive and time-consuming full autopsies being performed. As a result, more staff time would become available for other activities, such as in-service training.

As such, we recommend that the Chief Medical Examiner prepare a policies and procedures manual for the Pathology Section which includes (a) definitions and criteria for each forensic examination procedure (e.g. full autopsy, partial autopsy, external examination, etc.) and special procedure (e.g. SIDS protocol, motor vehicle accidents, etc.) conducted in the San Francisco Medical Examiner"s Office; and (b) a detailed description of the steps involved in performing each of these procedures. This would result in (a) less confusion over and more consistent use of required procedures and (b) better informed staff.

Staffing Levels

Through our review of practices in other jurisdictions as compared to the practices of the San Francisco Medical Examiner"s Office, we found that the overall workload per Pathologist is lower in San Francisco than in many other jurisdictions. As such, we believe that the current workload does not justify the need for five authorized Forensic Pathologist positions, each with a salary and fringe benefit package costing between $132,897 and $161,571 per year. Moreover, (a) expanding the opportunities for performing alternative, less time-consuming procedures, as recommended above, and (b) greater participation by the Chief Medical Examiner in performing autopsies, would further reduce the need for five of these highly qualified yet expensive positions.

Our survey indicated that the overall caseload per Forensic Pathologist in the San Francisco Medical Examiner"s Office is below the median for the nine other jurisdictions surveyed. Table VII.1.2 below shows the number of authorized physician staff dedicated to conducting autopsies and external examinations in each of the nine jurisdictions surveyed (excluding the chief medical examiner), the number of full autopsies per physician and the number of cases per physician, as compared to San Francisco.

Table VII.1.2
Annual Caseload per Pathologist by Jurisdiction

Table VII.1.2 illustrates that, although San Francisco is near the median in terms of the number of full autopsies per Forensic Pathologist per year, the overall caseload per Forensic Pathologist in San Francisco is approximately 43 percent lower than the median for the eight other jurisdictions which responded. Regardless of the number of full autopsies being performed, the overall caseload in San Francisco does not justify the need for five authorized Forensic Pathologists.

According to the Chief Medical Examiner, it takes on average two to three hours to perform a full autopsy, with some autopsies taking much longer, and some much less time. Each Forensic Pathologist in San Francisco conducts only 1.2 autopsies per day. [2] This is consistent with our findings in other jurisdictions. In addition, Forensic Pathologists perform other duties, such as conducting external examinations, dictating medical findings, preparing case reports and appearing in court. However, the remaining work that must be conducted by the Forensic Pathologists in San Francisco does not approach the amount of work that must be completed by Forensic Pathologists in other jurisdictions.

In San Francisco, the five Forensic Pathologists must complete an additional 250 to 260 partial examinations. This is equivalent to 50 to 52 partial examinations per Pathologist on an annual basis. Forensic Pathologists in other jurisdictions such as Los Angeles, Cook County, San Diego and so forth, must also complete partial autopsies, external examinations and sign-outs in order to fully discharge their duties. This variance in total workload is illustrated in Table VII.2.

The Budget Analyst is not recommending a reduction in overall staffing for the Pathology Section The Budget Analyst is recommending that (a) three 2582 Forensic Pathologist positions, two of which are currently vacant, be replaced by two less costly 2230 Physician Specialists; and (b) the Chief Medical Examiner begin performing autopsies on a routine basis.

The two new 2230 Physician Specialists which we are recommending should have completed a residency program and be Board eligible in anatomic pathology, consistent with the Civil Service minimum qualifications for this particular classification. These two staff would be available to assist the two remaining Forensic Pathologists in performing autopsies and other procedures and conduct routine autopsies under the supervision of a Forensic Pathologist. However, the Physician Specialists should not be required to participate in the on-call rotations for Forensic Pathologists. In addition, consistent with the recommendations contained in this report (see Section VI: Organization), the Chief Medical Examiner should assist the Forensic Pathology staff in performing autopsies on a routine basis, handle after business hours on-call schedules Monday through Thursday, and rotate with the other Forensic Pathologists for weekend on-call schedules.

The elimination of three Forensic Pathologist positions would result in savings of $484,713 per year (consisting of $414,285 in salaries and $70,428 in fringe benefits). This would be partially offset by the cost of adding two new 2230 Physician Specialist positions, each with an entry level salary of $79,970 per year (versus a starting salary of $113,587 for 2582 Forensic Pathologists). The annual salary and fringe benefit cost of two new 2230 Physician Specialist positions would therefore be $187,130 (consisting of $159,940 in salaries and $27,190 in fringe benefits). Thus, the net savings from implementing these recommendations would be $297,583 per year, as follows: