Career choice and interdisciplinary education in forensic pathology: A cross-sectional study

Career choice and interdisciplinary education in forensic pathology: A cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Career choice and interdisciplinary education in forensic pathology: A cross-sectional study Jenna Aungst, Mark Giffen, Erik Handberg, Reade Quinton, Gail Parker, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5523141/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Apr, 2026 Read the published version in BMC Medical Education → Version 1 posted 4 You are reading this latest preprint version Abstract Background: Early engagement in medical education is critical to influencing career choice. Exacerbated by a rapidly accelerating specialization timeline, there is currently a national workforce shortage of forensic pathologists. This cross-sectional study explores the widespread challenges of recruiting and retaining trainees through a broad educational lens, addressing interdisciplinary factors associated with workforce pathways over time, academic affiliations, and underrecognized collaborative opportunities in medical examiner and coroner (ME/C) education programs. The purpose of this study is to perform a needs assessment of learners interested in forensic pathology and ME/C education programs in the United States. Methods: Two different surveys were developed and distributed to 1) forensic pathologists and individuals pursuing a career in forensic pathology, and 2) ME/C education programs. Measures included factors associated with interest in forensic pathology and characteristics of ME/C education programs in the United States. Associations were analyzed using Pearson’s chi-square and Kendall’s tau-b. Results: The sample included 313 participants and 163 ME/C education programs. Interest in forensic pathology emerged during residency (27%), medical school (26%), and high school (24%), with increases occurring earlier in the education timeline from non-traditional pre-medical majors, careers, and medical subspecialties. Impactful career choice factors included rotations during medical school/residency and the influence of professors/mentors. ME/C education programs predominately targeted medical students (92%) and residents (76%) by providing opportunities for autopsy observation. Although 48% of medical schools are affiliated with an ME/C office, only 5% of ME/C offices are facilitating these experiences. There is no association between the number of affiliation agreements held by ME/C education programs and forensic pathologist output. Interdisciplinary exposure during rotations is primarily limited to job shadowing with death investigators. Quantity of workload (65%), staffing (52%), and office space (52%) are the greatest barriers experienced by ME/C education programs. Conclusions: This study underscores the critical need for interdisciplinary collaboration and sustainable, innovative educational approaches to strategically engage future forensic pathologists. Proposed strategies include 1) facilitating rotations to a diverse student and interprofessional population; 2) increasing community engagement; 3) strengthening clinical and academic affiliations; and 4) empowering ME/C education programs with resources and support. Clinical trial number: Not applicable forensic pathology medical education interdisciplinary workforce pipeline career choice pathways Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 I. Introduction Engagement with prospective students and trainees early in the educational timeline is critical to addressing the physician shortage in the United States. Since the COVID-19 pandemic, there has been a record imbalance between workforce supply and demand in medicine that is projected to accelerate to crisis proportions over the next decade. 1 Subspecialties such as forensic pathology are no exception, with a lack of career path exposure, ever-growing national caseload, escalating violent crime and opioid mortality, and increasing physician retirement contributing to the shortage. 2-3 Currently, there are approximately 862 full-time, board-certified forensic pathologists practicing in the United States. 4 The optimal number of forensic autopsy evaluations is 1 per 1,000 deaths. 5 When taking into account the current United States population, approximately 1,400 forensic pathologists would be required to perform the maximum number of 250 autopsies per pathologist according to accreditation standards established by the National Association of Medical Examiners (NAME). 6 Considering additional duties of the forensic pathologist, such as education, advocacy, research, medicolegal consultation, military service, and public health data reporting and monitoring, an estimated 2,520 or more full-time practicing forensic pathologists are needed for adequate support. 4 Based on these estimates, the current forensic pathology workforce is operating at approximately 34% of what is required. The impact of this shortage on public safety and community health will produce disastrous consequences, as forensic pathologists working in ME/C systems are the foundation for public health and safety while providing necessary answers to the most significant indicators of population health— morbidity and mortality. 7 Career choice in the medical subspecialty workforce is a dynamic process that is fluid early in the educational timeline. Commonly, it is influenced by lifestyle, work-life balance, and discipline interests. 8-10 Currently, an increasing number of students are changing career preferences to pathology during their medical education. 11 Since pathology trainees often enter into practice where they train as student physicians, this trend has positive implications for these regions that are also experiencing workforce shortages. 12 The development of an educational pipeline is a well-known method to secure future physician candidates. According to a 2008 survey by Hanzlick et al., interest in the forensic subspecialty primarily emerges in residency and medical school. 13 In 2020 and 2022, two studies examined factors influencing U.S. allopathic and osteopathic medical students to specialize in pathology. 14-15 Both studies associated pathology interest groups, research, and autopsy exposure with an increased likelihood of specialization in pathology. In contrast, lack of exposure during medical school, lack of portrayal on social media, and negative perceptions of the job market were noted as barriers to students pursuing pathology specialization. Present studies addressing education in forensic pathology predominately examine residency and fellowship programs, often analyzing curriculum structure, trainee evaluation, and program recruitment timelines. 16-17 Additional research on career choice and education in pathology examines the entire specialty and lacks assessment of the broad educational continuum outside of medical school, residency, and fellowship. A review of the current literature reveals gaps in studies addressing the relationship between national education trends and career choice in forensic pathology. The purpose of this study is to perform a needs assessment of learners interested in forensic pathology and medical examiner/coroner (ME/C) education programs in the United States. Program characteristics are compared to factors associated with individual career choice in forensic pathology and opportunities are identified to increase exposure to forensic pathology early in the educational timeline. Interdisciplinary and academic approaches to combat the workforce shortage will be discussed, including the establishment and advancement of nontraditional internships, student rotations, and shadowing opportunities. Barriers to the implementation of these programs and their solutions will be addressed, as will possible avenues for their future expansion. II. Methods A. Study Setting and Population Two surveys were developed and distributed using Qualtrics TM software between March and June 2023 (Qualtrics, Provo, UT). These surveys, referred to as ‘Interest’ and ‘Education,’ consisted of 21 and 36 questions, respectively. Measures were selected based on goals and objectives outlined in the 2022-2030 National Association of Medical Examiners (NAME) Strategic Plan and recommendations of the NAME Workforce Development Subcommittee, a working group instituted in 2019 to address recruitment and retention in forensic pathology. 18 NAME is the professional society of forensic pathologists and medicolegal death investigators that aims to advance forensic medicine through education, advocacy, collaboration, and leadership. Additional considerations for survey development included authors’ experience with educational outreach in a ME/C setting and previous studies describing factors that influenced the selection of pathology as a career choice. 13-15 According to requirements of the human subject protections regulations, as described in 45 CFR 46.104, these surveys were approved as category 2 exempt by the Institutional Review Board at Lincoln Memorial University-DeBusk College of Osteopathic Medicine. During a four-week period between July and August 2023, the surveys were distributed via email to the 1,552 members of NAME who had opted to receive electronic correspondence. B. Inclusion/Exclusion Criteria The ‘Interest’ survey included responses from a) practicing forensic pathologists; b) retired forensic pathologists; and c) individuals planning to pursue a career in forensic pathology (i.e., medical students, residents, and fellows). Participants who were not forensic pathologists and did not plan to pursue a career in forensic pathology were excluded (n = 13). The ‘Education’ survey included responses from representatives of ME/C education programs, primarily forensic pathologists (n = 163). C. Conceptual Framework This study applies Kern’s six-step approach to curriculum development. The Kern model emphasizes the need for problem identification and general needs assessment, targeted needs assessment, goals and objectives, educational strategies, implementation, and evaluation. 19 The general assessment involved the identification of the problem (i.e., the subspecialty workforce shortage) through a comparative analysis of current and ideal approaches. This was performed via a review of the literature and NAME Workforce Development Subcommittee meetings. The survey instruments utilized in this study reinforced the general assessment while serving as the targeted assessment of this model. The targeted needs assessment analyzed learners and their learning environment, including perceptions, stakeholders, resources, and barriers. D. Analytic Strategy Pearson’s chi-square analysis was used to establish the presence of statistically significant differences between the emergence of interest in forensic pathology by education level in 2008 and 2023. 13 Kendall’s tau-b was used to assess whether there was an association between the number of academic affiliation agreements held by ME/C offices and forensic pathologist output. Analyses were conducted in IBM SPSS Statistics for Mac, version 29.0.2.0 (SPSS Inc., Chicago, IL) and p-values of less than 0.05 were considered statistically significant. Missing responses and participants that selected ‘Prefer not to answer’ or ‘Not applicable’ were excluded from data reports and analyses. III. Results Responses were received from a total of 476 participants. The ‘Interest’ survey had 313 participants and a response rate of 20%. Participants demographics consisted of 84% forensic pathologists (n = 244), 6% pathology residents (n = 18), 5% medical students (n = 16), 4% fellows (n = 11), and 1% other (i.e., death investigators and pathologists’ assistants; n = 3). Most participants were female (53%, n = 143) between the ages of 30-39 (28%, n = 79). The ‘Education’ survey included 163 participants, each representing a single ME/C education program. The response rate was 11%. The highest geographic density of programs was located in the eastern United States (Figure 1). There are currently 2,040 ME/C offices in the U.S. 20 Based on survey responses, 5% are affiliated with an academic institution (n = 98). Of the 155 allopathic and osteopathic medical schools in the U.S., 48% were affiliated with an ME/C office (n = 74). 21 Each affiliated ME/C office had a mean of 2 academic affiliations ( SD = 2.02). There was no statistically significant association between the number of affiliation agreements held by each ME/C office and the output of forensic pathologists ( r 𝜏 = 0.063, p = 0.56). Of the 163 ME/C education programs participating in this study, 77% reported facilitating student rotations during the 2023-2024 academic year (n = 126). For many respondents, interest in forensic pathology first emerged during medical school (26%, n = 70) and residency (27%, n = 74) (Figure 2). During medical school, there were no significant differences between participants who became interested in the first year (24%, n = 16), second year (25%, n = 17), third year (25%, n =17), and fourth year (26%, n =18). For those that became interested during residency, interest emerged primarily in post-graduate training year 2 (39%, n = 28), followed by post-graduate year 3 (28%, n = 20), post-graduate year 1 (26%, n = 19), and post-graduate year 4 (7%, n = 5). In comparison to the 2008 study, there was a significant decrease in the emergence of interest in forensic pathology during residency (p < 0.001). 13 This was contrasted by increases in interest during middle school (p = 0.03), high school (p < 0.001), and graduate (non-medical) school (p < 0.001). Shifts in other education or training levels involved participants becoming interested while in practice (n = 5), other fellowships (n = 4), second residency (n = 2), and other programs or careers (n = 7). Of the 120 ME/C education programs facilitating student and trainee rotations, many offered opportunities for medical students (93%, n = 111), residents (76%, n = 91), graduate (non-medical) students (63%, n = 75), and undergraduate students (50%, n = 60). Fewer programs facilitated high school students (14%, n = 17), fellows (12%, n = 14), and pathologists’ assistant students (4%, n = 5). Other rotations opportunities involved law students (n = 1), paramedicine students (n = 1), physician assistant students (n = 1), and military mortuary affairs trainees (n = 1). Currently, the ME/C education programs that offer rotations for medical students mostly facilitate elective rotations (94%, n = 89), followed by non-credit (16%, n = 15) and core rotations (14%, n = 13). These programs accommodate a mean of 2.1 medical students per office monthly ( SD = 0.8). During their rotation, 5% of programs require their medical students to draft an autopsy report (n = 6). Of the ME/C education programs that facilitate resident rotations, both elective (75%, n = 61) and core (73%, n = 59) rotations are offered at similar rates. These programs accommodate a mean of 1.6 residents monthly per office ( SD = 0.8) and 42% require their residents to draft an autopsy report during their rotation (42%, n = 50). Student engagement discrepancies were identified using the difference between ME/C education program outreach and the education level at which interest in forensic pathology emerged (Figure 3). Based on survey responses, a larger proportion of students developed interest during middle and high school than to reported ME/C outreach targeted at those education levels. In contrast, more ME/C outreach was directed at undergraduate, graduate (non-medical), and medical students than interest emergence. Statistically significant differences between outreach and interest were noted at the high school, undergraduate, graduate (non-medical), and medical school education levels. Approximately 20% of ME/C education programs reported participating in career days or professional job fairs (n = 33). Most programs participated in 1 to 3 guest speaking opportunities per year (46%, n = 75). Out of the 50 ME/C offices with internship programs, students participated in forensic/lab-based (64%, n = 32), investigative (64%, n = 32), public health (14%, n = 7), forensic anthropology (10%, n = 5), and administrative roles (10%, n = 5). Other reported internships involved forensic photography (n = 1) and toxicology (n = 1). Most ME/C education programs facilitating internships offered less than 5 positions per year (61%, n = 22). Educational experiences offered by ME/C education programs consisted primarily of hands-on experiences (83%, n = 87), didactic lectures (70%, n = 74), and job shadowing (60%, n = 63). Fewer offices facilitated textbook reading assignments (39%, n = 41). small group discussions (38%, n = 40), quizzes and exams (18%, n = 19), journal club (16%, n = 17), and guest speakers (10%, n = 11). Programs allowed students to observe at autopsy (96%, n = 115), attend didactic lectures (73%, n = 88), eviscerate and record organ weights (71%, n = 85), participate in dissection (68%, n = 82), attend court testimony (68%, n = 81), attend scene investigations (59%, n = 71), perform research (38%, n = 46), attend meetings with law enforcement and attorneys (30%, n = 36), log and photograph evidence (23%, n = 27), attend meetings with decedent families (15%, n = 18), perform toxicology screens (14%, n = 17), and complete data requests (13%, n = 16). Other activities included participation in case conferences (n = 4) and fatality reviews (n = 1). In addition to attending meetings with related professions, interdisciplinary exposure was most often facilitated via tours and job shadowing. Out of the 43% of ME/C education programs offering dedicated interdisciplinary exposure (n = 70), this included shadowing death investigators (84%, n = 59), forensic anthropologists (34%, n = 24), toxicologists (27%, n = 19), crime laboratory scientists (24%, n = 17), histologists (16%, n = 11), district attorneys (9%, n = 6), public defenders (6%, n = 4), and organ procurement agencies (1%, n = 1). During the completion of undergraduate coursework, 50% of participants designated biology and/or medical science as their primary field of study (n = 134) (Figure 4). This included sub-categories within biology, such as microbiology (n = 4), zoology (n = 2), and entomology (n = 1). Participants also studied chemistry (13%, n = 35), biochemistry (6%, n = 16), psychology (8%, n = 21), anthropology (6%, n = 15), criminal justice (2%, n = 5), public health (1%, n = 4), neuroscience (1%, n = 3), business administration and management (including advertising and finance) (1%, n = 3), and computer and information sciences (<1%, n = 1). Other fields of study included foreign language (n = 9), forensic science (n = 8), religion (n = 4), engineering (n = 3), mathematics (n = 3), physics (n = 3), exercise science and physiology (n = 2), nutrition science (n = 1), and computer science (n = 1). Prior to attending medical school, 24% of participants pursued a graduate degree, with most designating biology and medical science as their fields of study (33%, n = 19). Additional graduate (non-medical) fields of study included public health (14%, n = 8), forensic science and medicine (9%, n = 5), neuroscience (7%, n = 4), chemistry (4%, n = 2), and anthropology (4%, n = 2). Other graduate fields of study were pathology (n = 4), law (n = 4), pathologists’ assistant (n = 1), anatomy (n = 1), physician assistant (n = 1), education (n = 1), biomechanics (n = 1), exercise physiology (n = 1), and foreign language (n = 1). Participants considered a mean of 1.9 non-pathology specialties during their education and training before selecting forensic pathology as a career choice ( SD = 1.5). Family medicine (23%, n = 60), emergency medicine (19%, n = 50), internal medicine (18%, n = 47), surgery (18%, n = 46), psychiatry (17%, n = 43), radiology (15%, n = 40), and obstetrics and gynecology (13%, n = 34) were most common. Other specialties considered included orthopedics (n = 18), anesthesiology (n = 16), dermatology (n = 15), critical care (n = 8), geriatric medicine (n = 3), neurology (n = 13), oncology (n = 11), ophthalmology (n = 9), otolaryngology (n = 6), urology (n = 5), cardiology (n = 3), nephrology (n = 3), infectious disease (n = 1), palliative care (n = 1), nuclear medicine (n = 1), and physical medicine and rehabilitation (n = 1). Interestingly, 24 participants exclusively considered forensic pathology during their education and training, while only 8 participants indicated that they considered non-forensic pathology. Factors that were most influential to participant interest in forensic pathology included rotations during residency (54%, n = 142), the influence of a professor or mentor (49%, n = 128), rotations during medical school (41%, n = 108), shadowing a forensic pathologist (37%, n = 98), reading books (32%, n = 84), and meeting someone in the field (31%, n = 82). Hearing lectures (28%, n = 74), watching television shows and movies (24%, n = 64), previous work experience (12%, n = 32), volunteering (10%, n = 26), and the influence of peers (8%, n = 20) were also contributory. Participants that indicated their previous work experience contributed to their interest have held positions as autopsy technicians (19%, n = 6), death investigators (9%, n = 3), pathology researchers (9%, n = 3), pathologists’ assistants (6%, n = 2), anatomical dissectors and diners (6%, n = 2), and medical examiner’s office security (3%, n = 1). Some participants also indicated that they had experience in funeral service (6%, n = 2), organ and tissue recovery (6%, n = 2), and nursing (3%, n = 1). Other factors consisted of life experiences (n = 8), learning experiences during other education levels (n = 5), reading newspapers or websites (n = 3), internet searches (n = 1), and a lack of other specialty options for international medical graduates to practice in the U.S. (n = 1). Job satisfaction associated with a career choice in forensic pathology was overwhelmingly positive, with most participants indicating that they strongly agreed, somewhat agreed, or agreed with key factors impacting specialty choice (Figure 5). Participants considered forensic pathology to be intellectually challenging (95%, n = 202) and exciting/rewarding (90%, n = 195). They were satisfied with their decision to pursue a career in the field (92%, n = 192), their lifestyle (83%, n = 179), and their income (72%, n = 155). Additionally, they felt they had sufficient opportunities for social interaction (76%, n = 166). In contrast, only 27% felt that they received sufficient exposure to the field in medical school (n = 57) and 25% considered the perception of the field as a specialty choice as positive (n = 56). Of the 271 individual respondents, 43% reported participating in a pathology student interest group while in medical school (n = 116). In contrast, only 30% of ME/C education programs collaborated with pathology student interest groups to promote available student rotations and engage in outreach efforts (40%, n = 34). Additional strategies employed to connect with students included utilizing academic institution websites (52%, n = 45), listing rotations on the ME/C office website (30%, n = 26), using an online rotation database such as the NAME International Training Organization Database or Association of American Medical College Visiting Student Learning Opportunities ™ (17%, n = 15), participating in career days (14%, n = 12), posting on online recruiting platforms such as Handshake (5%, n = 4), or social media (2%, n = 2). Several participants indicated that their organization does not advertise (n = 6) or coordinates student rotations directly with an academic institution (n = 6). Many ME/C education programs identified the quantity of workload (65%, n = 60), adequate staffing (52%, n = 49), and physical office space (52%, n = 48) as the greatest barriers to implementing and facilitating student rotations. Staff motivation (40%, n = 37), distribution of workload (33%, n = 31), legal/liability (33%, n = 31), funding (33%, n = 31), lack of academic institution response (23%, n = 21), and digital competence (3%, n = 3) were also contributory. Other factors included lack of stakeholder support (n = 5) and absence of student/trainee engagement (n = 2). Of the 163 ME/C education programs, 17% provided suggestions on how educational initiatives can be supported at their office in the future (n = 27). Themes included the development of an educational toolkit containing curriculum models, online modules, open access learning materials (e.g., lectures, slides, media, clinical cases), a user-friendly database for educational opportunities, stakeholder outreach materials, and stipends for internships and away rotations. IV. Discussion This study demonstrates that forensic pathology is beginning to see an influx of interest developing earlier in the medical education timeline from non-traditional pre-medical majors, alternate career paths, and other medical specialties. Presently, these groups are not a substantial target of ME/C educational outreach. Further, discrepancies exist between existing outreach efforts and the educational levels at which interest is emerging in forensic pathology. Taken together, these findings suggest that more complex factors are contributing to demographic shifts within the forensic pathology workforce and that student exposure through innovative, unconventional routes is necessary to address the workforce shortage. Multiple avenues exist to reach these groups of prospective recruits. Potential opportunities include: 1) facilitating rotations to a more diverse student and interprofessional population; 2) increasing community engagement (e.g., open-access lecture series and social media); 3) strengthening clinical and academic affiliations (e.g., curriculum-relevant didactics, student/trainee shadowing and rotations, and interdisciplinary research); and 4) empowering ME/C education program outreach with resources and support. 22 Overall, lifestyle and job satisfaction measures for forensic pathologists in this study were comparable to many of the happiest specialties in medicine, such as pediatric medicine, dermatology, and ophthalmology. 23-25 Conversely, the recorded responses reflect that the perception of forensic pathology as a viable career choice in medicine remains enduringly negative, potentially due to widely held misconceptions that forensic pathology lacks opportunities for social interaction, intellectual challenge, and professional fulfillment. 14-15,26 With the vast majority of respondents indicating that they find their career rewarding and have sufficient opportunities for social interaction (i.e., through meaningful interactions with decedents’ families, providing expert court testimony, and collaborating with the medicolegal community), the findings of this study directly dispute these misperceptions. Further, participants felt they did not receive sufficient exposure during medical school. Existing research emphasizes the importance of optimizing curricular design to increase student specialty exposure during the preclinical years. 11 However, with 70% of allopathic medical schools utilizing an integrated, systems-based core curriculum, schools are unlikely to incorporate subspecialty-specific lectures into an already rigorous curriculum. 27 Potential solutions to addressing a lack of curricular integration before residency may involve increasing the total number of faculty appointments and affiliation agreements between ME/C offices and academic institutions. This framework can promote didactic collaboration and experiential learning opportunities, thereby strengthening the development of an educational pipeline for students who may be interested in forensic pathology. Currently, 71% of medical school-based pathology departments offer faculty appointments to forensic pathologists at affiliated offices. 28 Similar agreements are often available through undergraduate and graduate (non-medical) programs, however, this study found that only 5% of ME/C offices are affiliated with an academic institution. Affiliations are beneficial because they permit ME/C offices access to potential funding, equipment, professional development resources, and new opportunities for student engagement (i.e., curricular inclusion via preclinical lectures). Preclinical didactic lectures developed by forensic pathologists on curriculum-related and board-relevant topics can provide subspecialty access for students, improve institutional receptiveness, and demonstrate the clinical applicability and interdisciplinary relevance of forensic pathology. While delivering lecture content, an affiliated forensic pathologist can promote forensic pathology as a career choice and advocate for shadowing, rotations, or active learning opportunities in ME/C offices, thereby cultivating interest and increasing awareness of forensic pathology. This study reinforces that early engagement through these methods with follow-up rotation opportunities is critical to securing student specialization. However, 52% of medical schools are not affiliated with a ME/C office. The students at these schools are likely unable to experience forensic pathology in a practical setting until their fourth year of medical school, when they gain access to the AAMC Visiting Student Learning Opportunities (VSLO®) program. This is rapidly becoming too late to influence students in their career choice timeline. Fourth-year medical students primarily utilize VSLO® to secure “audition” rotations, where they are expected to have decided on a specialty and trial potential residency programs. For the 1.4% of U.S. medical students that match into a pathology residency, these rotations may or may not include forensic autopsy. 29 Considering the need for early specialty exposure, this leads to the question— should existing ME/C education programs take on more academic affiliations to reach more students? Statistical analysis in this study indicated that ME/C offices with more affiliation agreements do not necessarily generate more forensic pathologists, suggesting that a quality-over-quantity approach is higher yield to combat the workforce shortage. Ultimately, the solution is not for existing ME/C education programs with limited resources to take on more affiliation agreements. As evidenced by this study, resource exhaustion and burnout need to be addressed prophylactically. Forensic casework and staff well-being take precedence, as these establish the foundation for program success. The solution to increasing student reach is two-fold: 1) ME/C offices without education programs need to be empowered with the appropriate resources to establish stable, high-quality outreach initiatives; and 2) existing ME/C education programs need to be supplemented with additional resources to capitalize on their success by refining their curriculum, collaborating and innovating with other disciplines, and helping guide the outreach efforts of ME/C offices seeking to establish new programs. In an ME/C setting, rotating students and trainees can be readily integrated into office workflow and trained to assist with a multitude of competency-matched entrustable professional activities at the discretion of the staff, parameters of the affiliation agreement, and insurance coverage. Potential activities include data entry, case digitization, quality assurance, data request completion, social media, public outreach, research, presentation preparation, evidence processing, specimen procurement, photography, and evisceration. This study established that fewer than half of current ME/C education programs are utilizing students and trainees in this capacity. From a learning perspective, the Accreditation Council for Graduate Medical Education emphasizes the need for graded, progressive responsibility in educational settings to promote professional development and autonomous practice. 30-31 Supplementing office operations with students and trainees serves the dual benefit of empowering staff and enhancing efficiency by allowing for the reallocation of staff work hours to more complex and larger-scale initiatives. After expanding their utilization of medical students and trainees, several ME/C offices included in this study increased their focus on innovative technology, grant procurement, community outreach, additional training, and other avenues for workforce development and retention. Broadly, policymakers and resource allocators tend to view this type of educational and innovative capacity as positive, which can further enhance office potential. 32 In recent years, there has been a rise in collaboration between interdisciplinary professionals and ME/C offices. Disciplines such as forensic anthropology, radiology, molecular genetics, genealogy, entomology, and epidemiology are becoming increasingly utilized in a medicolegal setting. 33-39 Additionally, growing numbers of forensic pathologists are entering the workforce with other subspecialty training. At the time of this study, 16% of incoming forensic pathology fellows have completed additional fellowships in pediatric pathology or neuropathology. 40 This study identified a variety of interdisciplinary fields with the potential to strengthen pipeline diversity and provide alternative avenues for recruitment. Notably, respondents demonstrated a high prevalence of other specialty considerations during the educational and training timeline, as well as themes in undergraduate and graduate (non-medical) fields of study that apply to forensic medicine (i.e., chemistry, public health, neuroscience, anthropology). Engaging with students from these disciplines may serve the added benefit of addressing specific needs of individual ME/C offices in the form of entrustable professional activities. For example, many graduate (non-medical) students are required to produce a deliverable work product for the completion of their degree programs. Matching eligible students with pertinent interests to necessary projects offers creative opportunities that appeal to a broader population, resulting in a mutually beneficial relationship and the potential to produce an increasingly diverse and productive workforce. This study established that engagement barriers experienced by ME/C offices are primarily resource-oriented (i.e., quantity of workload, staffing, and physical office space). Many of the suggestions made by participants to support educational initiatives have the potential the reduce these barriers. However, funding opportunities for ME/C education are limited. Currently, these are primarily intended for forensic pathology fellowship programs or increasing training opportunities for existing forensic pathologists. For example, the Bureau of Justice Administration (BJA) Paul Coverdell Forensic Science Improvement Grant Program indirectly supports the education and training of forensic pathologists by improving the quality and timeliness of forensic services. 41 Similarly, the BJA Strengthening the Medical Examiner-Coroner System Program funds fellowships by providing up to $150,000 per fellow, which can be used for salary benefits, administrative costs, and up to $50,000 for student loan repayment. 42 While fellowship funding is critical to training competent forensic pathologists, only 41.7% of forensic pathology fellowship programs filled in the most recent Match cycle. 43 This is an 8.3% decrease from the preceding year. 44 The findings of this study suggest that expanding funding opportunities for a broader educational scope is necessary to increase the number of forensic pathology fellowship applicants and address the subspecialty workforce shortage. This study underscores the critical need for interdisciplinary collaboration in forensic pathology. The current workforce shortage necessitates comprehensive and sustainable educational strategies to cultivate a robust pipeline of future forensic pathologists, while broadly enhancing support and awareness of the field. Empowering ME/C offices to adopt strategic, innovative, and collaborative methods in medical education is pivotal to accomplish this. By providing ME/C offices with the necessary resources and support, we can overcome existing barriers, bolster the current workforce, and successfully engage the next generation of forensic pathologists. V. Declarations A. Ethics approval and consent to participate: This study has been approved as category 2 exempt by the Institutional Review Board at Lincoln Memorial University-DeBusk College of Osteopathic Medicine (IRB00006284). Informed consent was obtained from participants during survey completion. B. Consent for publication: Not applicable. C. Availability of data and materials: The datasets obtained during the current study are available from the corresponding author on reasonable request. D. Competing interests: None of the authors have a conflict of interest to disclose. E. Funding: None. F. Author contributions: JA: conceptualization, methodology, data curation, formal analysis, visualization, writing—original draft. MG: conceptualization, methodology, data curation, writing—original draft. EH: writing— review & editing. RQ: conceptualization, writing— review & editing, supervision. GP: conceptualization, visualization, writing—original draft. JF: writing—review & editing. LB: writing—review & editing. AK: formal analysis, writing—review & editing. MJM: conceptualization, writing— review & editing, supervision. GG: writing— review & editing. JG: conceptualization, methodology, data curation, writing—original draft, supervision. All authors read and approved the final manuscript. G. Acknowledgements: The authors wish to thank Brandi McCleskey, MD and the Board of Directors of the National Association of Medical Examiners for their support and dedication to workforce development in forensic pathology. We would like to thank Amanda McCoy for her assistance with data analysis during the preparation of this manuscript. We would also like to thank Rachel Geller, MD, Marquel Johnson, Julio Alicea, and Crystal Lee, MPH for their leadership and contributions to the establishment and growth of an innovative education program in DeKalb County, Georgia. References American Association of Medical Colleges. The complexities of physician supply and demand: Projections from 2019 to 2034. 2021 Jun [cited 2024 Jan 10]. Available from: https://www.aamc.org/media/54681/download Weedn VW. & Menendez MJ. Reclaiming the autopsy as the practice of medicine: A pathway to remediation of the forensic pathology workforce shortage. 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BMJ Open . 2019;9(3):e022097. doi: 10.1136/bmjopen-2018-022097 Rachoin JS, Olguta Vilceanu M, Franzblau N, Gordon S, Cerceo E. How often do medical students change career preferences over the course of medical school? BMC Med Educ . 2023;23:596. doi: 10.1186/s12909-023-04598-2 Murphy B. Where to practice after residency: Your specialty can tell the tale. American Medical Association . 2020 Jul 7 [cited 2024 Jan 2]. Available from: https://www.ama-assn.org/medical-residents/transition-resident-attending/where-practice-after-residency-your-specialty-can Hanzlick R, Prahlow JA, Denton S, Jentzen J, Quinton R, Sathyavagiswaran L, et al. Selecting forensic pathology as a career: A survey of the past with an eye on the future. Am J Forensic Med Pathol . 2008;29(2):114-122. doi: 10.1097/PAF.0b013e318174f0a9 George MR, Johnson KA, Berg MP, Bryant BH, Childs JM, Dixon LR, et al. Factors influencing US osteopathic medical students to choose pathology as a specialty. 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Baltimore, MD: Johns Hopkins University Press; 1998. Brooks C. Medical examiner and coroner offices, 2018. U.S. Department of Justice. Bureau of Justice Statistics. NCJ-302051. 2021 Nov 4 [cited 2023 25 Sept]. Available from: https://bjs.ojp.gov/content/pub/pdf/meco18.pdf International Medical Aid. How many medical schools in the US: The definitive guide (2023). 2023 Sept 7 [cited 2023 Dec 31]. Available from: https://medicalaid.org/how-many-medical-schools-in-us-the-definitive-guide-2023/ Taylor M. Stopping the shortage ‘cycle’: Ways to fortify the forensic pathology workforce. Forensic Magazine . 2023 Feb 22 [cited 2023 Dec 31]. Available from: https://www.forensicmag.com/3425-Featured-Article-List/594687-Stopping-the-Shortage-Cycle-Ways-to-Fortify-the-Forensic-Pathologist-Workforce/ Koval M. Medscape pathologist lifestyle, happiness, and burnout report 2023: Contentment amid stress. 2023 Feb 24 [cited 2024 Jan 10]. Available from: https://www.medscape.com/slideshow/2023-lifestyle-pathologist-6016088 Ligibel JA, Goularte N, Berliner JI, Bird SB, Brazeau CMLR, Rowe SG, et al. Well-being parameters and intention to leave current institution among academic physicians. JAMA Netw Open . 2023;6(12):e2347894. doi: 10.1001/jamanetworkopen.2023.47894 Leigh JP, Tancredi DJ, Kravitz RL. Physician career satisfaction within specialties. BMC Health Serv Res . 2009;9:166. doi: 10.1186/1472-6963-9-166 Jajosky RP, Coulson HC, Rosengrant AJ, Jajosky AN, Jajosky PG. Osteopathic students and graduates matching into pathology residency, 2011-2020. J Osteopath Med . 2021;121(2):149-156. doi: 10.1515/jom-2020-0134 McCloskey C, Brissette M, Childs JM, Lofgreen A, Johnson K, George MR, et al. How influential are medical school curriculum and other medical school characteristics in students’ selecting pathology as a specialty? Acad Pathol. 2023;10(2):100073. doi: 10.1016/j.acpath.2023.100073 Bailey D. The relationship between medical school-based pathology departments and affiliated forensic pathology training sites. Acad Pathol . 2021;8. doi: 10.1177/23742895211040208 National Resident Matching Program. Results and Data: 2024 Main Residency Match. 2024 June 28 [cited 2024 Aug 21]. Available from: https://www.nrmp.org/match-data/2024/06/results-and-data-2024-main-residency-match/ Accreditation Council for Graduation Medical Education. ACGME Common Program Requirements (Residency). 2022 Sept 17 [cited 2024 Mar 14]. Available from: https://www.acgme.org/globalassets/pfassets/programrequirements/cprresidency_2023.pdf Schnapp BH, Caretta-Weyer HA, Cortez E, Heinrich SA, Kraut AS, Lloyd CM, et al. Curated collections for clinician educators: Five key papers on graduated responsibility in residency education. Cureus . 2019;11(4):e4383. doi: 10.7759/cureus.4383 Observatory of Public Sector Innovation. Innovation capacity of governments: A systematic framework. 2022 Sept 19 [cited 2024 Jan 2]. Available from: https://oecd-opsi.org/wp-content/uploads/2022/09/OECD-OPSI-Innovative-Capacity-Framework.pdf Crowder CM, Wiersema JM, Adams BJ, Austin DA, Love JC. The utility of forensic anthropology in the medical examiner’s office. Acad Forensic Pathol . 2016;6(3):349-360. doi: 10.23907/2016.037 Weiss D, Mcleod-Henning D, Waltke H. Using Advanced Imaging Technologies to Enhance Autopsy Practices. NIJ Journal . 2018; 279. Available from: https://www.ojp.gov/pdffiles1/nij/250698.pdf American Society of Radiologic Technologists. Forensic Radiology Survey. 2008 Nov [cited 2024 Jan 2]. Available from: https://www.asrt.org/docs/default-source/research/asrtforensicradiographysurvey.pdf?sfvrsn=30b86d1e_4 Dowdeswell T. Forensic genetic genealogy: A profile of cases solved. Forensic Science International: Genetics . 2022;58:102679. doi: 10.1016/j.fsigen.2022.102679 Cunningham K. The promise of a molecular autopsy in forensic pathology practice. Acad Forensic Pathol . 2017;7(4): 551-566. doi: 10.23907/2017.047 Latimer R, MacLeod H, Dellefave-Castillo L, Macaya D, Hart TR. Postmortem genetic testing is an increasingly utilized tool in death investigation. Acad Forensic Pathol . 2022; 12(4):129-139. doi: 10.1177/19253621221124800 Council of State and Territorial Epidemiologists. CSTE Applied Forensic Epidemiology Workgroup 2022 Summary Report. 2023 Mar [cited 2024 Jan 3]. Available from: https://cdn.ymaws.com/www.cste.org/resource/resmgr/Applied_Forensic_Epi_Workgro.pdf Gill JR, DeJoseph ME, Aungst JL. Forensic pathology Match 2023: Resident survey results. Proceedings of the National Association of Medical Examiners Annual Meeting; 2023 Oct 16; San Jose, CA, US. Available from: https://name.memberclicks.net/assets/docs/MATCH%20Presentation%20at%20San%20Jose%20Annual%20NAME%20meeting%202023%20.pdf U.S. Bureau of Justice Assistance. Paul Coverdell Forensic Science Improvement Grants Program. 2023 Oct 31 [cited 2024 Mar 12]. Available from: https://bja.ojp.gov/program/coverdell/overview U.S. Bureau of Justice Assistance. Strengthening the medical examiner-coroner system program. 2023 Oct 16 [cited 2024 Jan 10]. Available from: https://bja.ojp.gov/program/strengthening-mec/overview National Resident Matching Program. Match Results Statistics: Forensic Pathology - 2024. 2024 May 1 [cited 2024 Aug 21]. Available from: https://www.nrmp.org/wp-content/uploads/2024/05/Forensic-Pathology-MRS-Report-2024.pdf National Resident Matching Program. Match Results Statistics: Forensic Pathology - 2023. 2023 May 1 [cited 2024 Aug 21]. Available from: https://www.nrmp.org/wp-content/uploads/2023/05/Forensic-Pathology-MRS-Report-2023.pdf Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 24 Apr, 2026 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 12 Mar, 2025 Editor assigned by journal 07 Mar, 2025 Submission checks completed at journal 07 Mar, 2025 First submitted to journal 25 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5523141","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":425476315,"identity":"ba4877ce-79d2-4e4a-be21-9ba818ae55c0","order_by":0,"name":"Jenna Aungst","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/0lEQVRIiWNgGAWjYBACxgZk3ocCGIuNOC2MjTMMQDQzfi0o2pt5iNHC3N577MEPBrvE7fzLnz+2MdiWuJ29/wDDh7LDuE3uOZdu2MOQnLhzxhvD5hyD24k7ew4zMM44h0fLjBwzCR4G5sQNN84wgrVsuJHMwMzbhkfL/Ddmkn8Y6oEqjz9stgBpuf+YgfkvPi0zeMykeRgOJ24432DYzAC2hZmBmRGflp4cM2kZg+PGG27wGM7sMbhtvOFMssFBoA9xajFsP2Mm+aaiWnbD+eMPPvyouC274fjBhw9+lFnj1tIAIkHRIZGAED2AUz0QyMNZ/HjVjYJRMApGwUgGAEikXOPvBJ8fAAAAAElFTkSuQmCC","orcid":"","institution":"Lincoln Memorial University-DeBusk College of Osteopathic Medicine","correspondingAuthor":true,"prefix":"","firstName":"Jenna","middleName":"","lastName":"Aungst","suffix":""},{"id":425476316,"identity":"4491e0ae-7323-440f-ae6a-a63c604b3e80","order_by":1,"name":"Mark Giffen","email":"","orcid":"","institution":"Department of Pathology, Wake Forest University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Mark","middleName":"","lastName":"Giffen","suffix":""},{"id":425476317,"identity":"fe23c7e7-b075-48e0-88f2-196776f0ab63","order_by":2,"name":"Erik Handberg","email":"","orcid":"","institution":"Fort Bend County Medical Examiner's Office","correspondingAuthor":false,"prefix":"","firstName":"Erik","middleName":"","lastName":"Handberg","suffix":""},{"id":425476318,"identity":"3d37b2e5-e12f-41ed-a457-b0bc31757d82","order_by":3,"name":"Reade Quinton","email":"","orcid":"","institution":"Department of Laboratory Medicine and Pathology, Mayo Clinic","correspondingAuthor":false,"prefix":"","firstName":"Reade","middleName":"","lastName":"Quinton","suffix":""},{"id":425476319,"identity":"befaff12-008b-42a9-b9a9-d792d0b38805","order_by":4,"name":"Gail Parker","email":"","orcid":"","institution":"DeKalb County Medical Examiner's Office","correspondingAuthor":false,"prefix":"","firstName":"Gail","middleName":"","lastName":"Parker","suffix":""},{"id":425476320,"identity":"ff9d9196-8c9b-4de3-8038-969b45f82775","order_by":5,"name":"Juniper Fedor","email":"","orcid":"","institution":"DeKalb County Medical Examiner's Office","correspondingAuthor":false,"prefix":"","firstName":"Juniper","middleName":"","lastName":"Fedor","suffix":""},{"id":425476321,"identity":"82877e3c-591b-4a1d-bb83-0b81df0e8efd","order_by":6,"name":"Lauren Bucci","email":"","orcid":"","institution":"DeKalb County Medical Examiner's Office","correspondingAuthor":false,"prefix":"","firstName":"Lauren","middleName":"","lastName":"Bucci","suffix":""},{"id":425476323,"identity":"859b50ff-f932-4d9e-961d-f330f43c6c23","order_by":7,"name":"Adam Kolatorowicz","email":"","orcid":"","institution":"Lincoln Memorial University-DeBusk College of Osteopathic Medicine","correspondingAuthor":false,"prefix":"","firstName":"Adam","middleName":"","lastName":"Kolatorowicz","suffix":""},{"id":425476326,"identity":"5d947784-afc6-41f2-96e9-ffb61ce262e9","order_by":8,"name":"M.J. Menendez","email":"","orcid":"","institution":"The Center for Forensic Science Research and Education","correspondingAuthor":false,"prefix":"","firstName":"M.J.","middleName":"","lastName":"Menendez","suffix":""},{"id":425476328,"identity":"243f19c9-a20f-454b-9fe3-c7205170eaad","order_by":9,"name":"Gerald Gowitt","email":"","orcid":"","institution":"DeKalb County Medical Examiner's Office","correspondingAuthor":false,"prefix":"","firstName":"Gerald","middleName":"","lastName":"Gowitt","suffix":""},{"id":425476329,"identity":"635be98e-0892-45e2-86b4-39a43dc2747a","order_by":10,"name":"James Gill","email":"","orcid":"","institution":"Connecticut Office of Chief Medical Examiner","correspondingAuthor":false,"prefix":"","firstName":"James","middleName":"","lastName":"Gill","suffix":""}],"badges":[],"createdAt":"2024-11-25 22:08:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5523141/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5523141/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-026-09227-2","type":"published","date":"2026-04-24T15:58:18+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":78224638,"identity":"041482d8-15f4-45d8-9cbd-8c3cc05b9cb3","added_by":"auto","created_at":"2025-03-11 06:51:08","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":68848,"visible":true,"origin":"","legend":"\u003cp\u003eGeographic distribution of ME/C education programs in the United States. Regional density was greatest in the eastern United States. The states with the highest number of programs were New York, Texas, and California.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5523141/v1/bae52073905295ed9487ead3.png"},{"id":78224640,"identity":"2bf39742-2d42-42cd-aa46-eb7af8ab9827","added_by":"auto","created_at":"2025-03-11 06:51:08","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":56306,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of the emergence of interest in forensic pathology by education level. * p-value \u0026lt; 0.05.\u003cbr\u003e\n\u003csup\u003ea\u003c/sup\u003eData derived from Hanzlick, et al.\u003csup\u003e13\u003c/sup\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5523141/v1/9c48b24eca3df91307d6792b.png"},{"id":78227056,"identity":"d7925697-9e5b-49f4-8cab-acd859f03dc2","added_by":"auto","created_at":"2025-03-11 07:07:08","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":55668,"visible":true,"origin":"","legend":"\u003cp\u003eDifferences between the emergence of interest in forensic pathology and ME/C education program outreach by education level. * p-value \u0026lt; 0.05.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5523141/v1/6918ee1a763cb3e5bdbfe82a.png"},{"id":78224650,"identity":"3006777e-b567-46d9-af69-185c901bd80b","added_by":"auto","created_at":"2025-03-11 06:51:08","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":69238,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of undergraduate and graduate (non-medical) fields of study prior to medical school matriculation.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5523141/v1/2c6e6b87627744885907b3cd.png"},{"id":78226311,"identity":"afd10153-3bca-4296-b12d-a10a07400e3b","added_by":"auto","created_at":"2025-03-11 06:59:08","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":89265,"visible":true,"origin":"","legend":"\u003cp\u003eLikert scale ratings of job satisfaction and perceptions associated with careers in forensic pathology.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-5523141/v1/b4959f82611e60d4a5388cad.png"},{"id":107928107,"identity":"952c041a-5b1c-4eee-bd70-9920bb859a38","added_by":"auto","created_at":"2026-04-27 16:08:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":513480,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5523141/v1/bc19542f-4c0e-4e78-946d-2d902dd3f6e5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Career choice and interdisciplinary education in forensic pathology: A cross-sectional study","fulltext":[{"header":"I. Introduction","content":"\u003cp\u003eEngagement with prospective students and trainees early in the educational timeline is critical to addressing the physician shortage in the United States. Since the COVID-19 pandemic, there has been a record imbalance between workforce supply and demand in medicine that is projected to accelerate to crisis proportions over the next decade.\u003csup\u003e1\u003c/sup\u003e Subspecialties such as forensic pathology are no exception, with a lack of career path exposure, ever-growing national caseload, escalating violent crime and opioid mortality, and increasing physician retirement contributing to the shortage.\u003csup\u003e2-3\u003c/sup\u003e Currently, there are approximately 862 full-time, board-certified forensic pathologists practicing in the United States.\u003csup\u003e4\u003c/sup\u003e The optimal number of forensic autopsy evaluations is 1 per 1,000 deaths.\u003csup\u003e5\u003c/sup\u003e When taking into account the current United States population, approximately 1,400 forensic pathologists would be required to perform the maximum number of 250 autopsies per pathologist according to accreditation standards established by the National Association of Medical Examiners (NAME).\u003csup\u003e6\u003c/sup\u003e Considering additional duties of the forensic pathologist, such as education, advocacy, research, medicolegal consultation, military service, and public health data reporting and monitoring, an estimated 2,520 or more full-time practicing forensic pathologists are needed for adequate support.\u003csup\u003e\u0026nbsp;4\u003c/sup\u003e Based on these estimates, the current forensic pathology workforce is operating at approximately 34% of what is required. The impact of this shortage on public safety and community health will produce disastrous consequences, as forensic pathologists working in ME/C systems are the foundation for public health and safety while providing necessary answers to the most significant indicators of population health\u0026mdash; morbidity and mortality.\u003csup\u003e7\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eCareer choice in the medical subspecialty workforce is a dynamic process that is fluid early in the educational timeline. Commonly, it is influenced by lifestyle, work-life balance, and discipline interests.\u003csup\u003e8-10\u003c/sup\u003e Currently, an increasing number of students are changing career preferences to pathology during their medical education.\u003csup\u003e11\u003c/sup\u003e Since pathology trainees often enter into practice where they train as student physicians, this trend has positive implications for these regions that are also experiencing workforce shortages.\u003csup\u003e12\u003c/sup\u003e The development of an educational pipeline is a well-known method to secure future physician candidates. According to a 2008 survey by Hanzlick et al., interest in the forensic subspecialty primarily emerges in residency and medical school.\u003csup\u003e13\u003c/sup\u003e In 2020 and 2022, two studies examined factors influencing U.S. allopathic and osteopathic medical students to specialize in pathology.\u003csup\u003e14-15\u003c/sup\u003e Both studies associated pathology interest groups, research, and autopsy exposure with an increased likelihood of specialization in pathology. In contrast, lack of exposure during medical school, lack of portrayal on social media, and negative perceptions of the job market were noted as barriers to students pursuing pathology specialization. Present studies addressing education in forensic pathology predominately examine residency and fellowship programs, often analyzing curriculum structure, trainee evaluation, and program recruitment timelines.\u003csup\u003e16-17\u003c/sup\u003e Additional research on career choice and education in pathology examines the entire specialty and lacks assessment of the broad educational continuum outside of medical school, residency, and fellowship. A review of the current literature reveals gaps in studies addressing the relationship between national education trends and career choice in forensic pathology.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The purpose of this study is to perform a needs assessment of learners interested in forensic pathology and medical examiner/coroner (ME/C) education programs in the United States. Program characteristics are compared to factors associated with individual career choice in forensic pathology and opportunities are identified to increase exposure to forensic pathology early in the educational timeline. Interdisciplinary and academic approaches to combat the workforce shortage will be discussed, including the establishment and advancement of nontraditional internships, student rotations, and shadowing opportunities. Barriers to the implementation of these programs and their solutions will be addressed, as will possible avenues for their future expansion.\u003c/p\u003e"},{"header":"II.\tMethods","content":"\u003cp\u003eA. \u003cstrong\u003eStudy Setting and Population\u003c/strong\u003e\u003cbr\u003eTwo surveys were developed and distributed using Qualtrics\u003csup\u003eTM\u003c/sup\u003e software between March and June 2023 (Qualtrics, Provo, UT). These surveys, referred to as \u0026lsquo;Interest\u0026rsquo; and \u0026lsquo;Education,\u0026rsquo; consisted of 21 and 36 questions, respectively. Measures were selected based on goals and objectives outlined in the 2022-2030 National Association of Medical Examiners (NAME) Strategic Plan and recommendations of the NAME Workforce Development Subcommittee, a working group instituted in 2019 to address recruitment and retention in forensic pathology.\u003csup\u003e18\u003c/sup\u003e NAME is the professional society of forensic pathologists and medicolegal death investigators that aims to advance forensic medicine through education, advocacy, collaboration, and leadership. Additional considerations for survey development included authors\u0026rsquo; experience with educational outreach in a ME/C setting and previous studies describing factors that influenced the selection of pathology as a career choice.\u003csup\u003e13-15\u003c/sup\u003e\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;According to requirements of the human subject protections regulations, as described in 45 CFR 46.104, these surveys were approved as category 2 exempt by the Institutional Review Board at Lincoln Memorial University-DeBusk College of Osteopathic Medicine. During a four-week period between July and August 2023, the surveys were distributed via email to the 1,552 members of NAME who had opted to receive electronic correspondence.\u003c/p\u003e\n\u003cp\u003eB.\u0026nbsp;\u003cstrong\u003eInclusion/Exclusion Criteria\u003cbr\u003e\u003c/strong\u003eThe \u0026lsquo;Interest\u0026rsquo; survey included responses from a) practicing forensic pathologists; b) retired forensic pathologists; and c) individuals planning to pursue a career in forensic pathology (i.e., medical students, residents, and fellows). Participants who were not forensic pathologists and did not plan to pursue a career in forensic pathology were excluded (n = 13). The \u0026lsquo;Education\u0026rsquo; survey included responses from representatives of ME/C education programs, primarily forensic pathologists (n = 163).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC. \u0026nbsp;Conceptual Framework\u003cbr\u003e\u003c/strong\u003eThis study applies Kern\u0026rsquo;s six-step approach to curriculum development. The Kern model emphasizes the need for problem identification and general needs assessment, targeted needs assessment, goals and objectives, educational strategies, implementation, and evaluation.\u003csup\u003e19\u003c/sup\u003e The general assessment involved the identification of the problem (i.e., the subspecialty workforce shortage) through a comparative analysis of current and ideal approaches. This was performed via a review of the literature and NAME Workforce Development Subcommittee meetings. The survey instruments utilized in this study reinforced the general assessment while serving as the targeted assessment of this model. The targeted needs assessment analyzed learners and their learning environment, including perceptions, stakeholders, resources, and barriers.\u003c/p\u003e\n\u003cp\u003eD. \u003cstrong\u003eAnalytic Strategy\u003c/strong\u003e\u003cbr\u003ePearson\u0026rsquo;s chi-square analysis was used to establish the presence of statistically significant differences between the emergence of interest in forensic pathology by education level in 2008 and 2023.\u003csup\u003e13\u003c/sup\u003e Kendall\u0026rsquo;s tau-b was used to assess whether there was an association between the number of academic affiliation agreements held by ME/C offices and forensic pathologist output. Analyses were conducted in IBM SPSS Statistics for Mac, version 29.0.2.0 (SPSS Inc., Chicago, IL) and p-values of less than 0.05 were considered statistically significant. Missing responses and participants that selected \u0026lsquo;Prefer not to answer\u0026rsquo; or \u0026lsquo;Not applicable\u0026rsquo; were excluded from data reports and analyses.\u003cbr\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"III. Results","content":"\u003cp\u003eResponses were received from a total of 476 participants. The \u0026lsquo;Interest\u0026rsquo; survey had 313 participants and a response rate of 20%. Participants demographics consisted of 84% forensic pathologists (n = 244), 6% pathology residents (n = 18), 5% medical students (n = 16), 4% fellows (n = 11), and 1% other (i.e., death investigators and pathologists\u0026rsquo; assistants; n = 3). Most participants were female (53%, n = 143) between the ages of 30-39 (28%, n = 79). The \u0026lsquo;Education\u0026rsquo; survey included 163 participants, each representing a single ME/C education program. The response rate was 11%. The highest geographic density of programs was located in the eastern United States (Figure 1). There are currently 2,040 ME/C offices in the U.S.\u003csup\u003e20\u003c/sup\u003e Based on survey responses, 5% are affiliated with an academic institution (n = 98). Of the 155 allopathic and osteopathic medical schools in the U.S., 48% were affiliated with an ME/C office (n = 74).\u003csup\u003e21\u003c/sup\u003e Each affiliated ME/C office had a mean of 2 academic affiliations (\u003cem\u003eSD\u003c/em\u003e = 2.02). There was no statistically significant association between the number of affiliation agreements held by each ME/C office and the output of forensic pathologists (\u003cem\u003er\u003c/em\u003e\u003csub\u003e𝜏\u003c/sub\u003e = 0.063, \u003cem\u003ep\u003c/em\u003e = 0.56). Of the 163 ME/C education programs participating in this study, 77% reported facilitating student rotations during the 2023-2024 academic year (n = 126).\u003c/p\u003e\n\u003cp\u003eFor many respondents, interest in forensic pathology first emerged during medical school (26%, n = 70) and residency (27%, n = 74) (Figure 2). During medical school, there were no significant differences between participants who became interested in the first year (24%, n = 16), second year (25%, n = 17), third year (25%, n =17), and fourth year (26%, n =18). For those that became interested during residency, interest emerged primarily in post-graduate training year 2 (39%, n = 28), followed by post-graduate year 3 (28%, n = 20), post-graduate year 1 (26%, n = 19), and post-graduate year 4 (7%, n = 5). In comparison to the 2008 study, there was a significant decrease in the emergence of interest in forensic pathology during residency (p \u0026lt; 0.001).\u003csup\u003e13\u003c/sup\u003e This was contrasted by increases in interest during middle school (p = 0.03), high school (p \u0026lt; 0.001), and graduate (non-medical) school (p \u0026lt; 0.001). Shifts in other education or training levels involved participants becoming interested while in practice (n = 5), other fellowships (n = 4), second residency (n = 2), and other programs or careers (n = 7).\u003c/p\u003e\n\u003cp\u003eOf the 120 ME/C education programs facilitating student and trainee rotations, many offered opportunities for medical students (93%, n = 111), residents (76%, n = 91), graduate (non-medical) students (63%, n = 75), and undergraduate students (50%, n = 60). Fewer programs facilitated high school students (14%, n = 17), fellows (12%, n = 14), and pathologists\u0026rsquo; assistant students (4%, n = 5). Other rotations opportunities involved law students (n = 1), paramedicine students (n = 1), physician assistant students (n = 1), and military mortuary affairs trainees (n = 1). Currently, the ME/C education programs that offer rotations for medical students mostly facilitate elective rotations (94%, n = 89), followed by non-credit (16%, n = 15) and core rotations (14%, n = 13). These programs accommodate a mean of 2.1 medical students per office monthly (\u003cem\u003eSD\u003c/em\u003e = 0.8). During their rotation, 5% of programs require their medical students to draft an autopsy report (n = 6). Of the ME/C education programs that facilitate resident rotations, both elective (75%, n = 61) and core (73%, n = 59) rotations are offered at similar rates. These programs accommodate a mean of 1.6 residents monthly per office (\u003cem\u003eSD\u003c/em\u003e = 0.8) and 42% require their residents to draft an autopsy report during their rotation (42%, n = 50).\u003c/p\u003e\n\u003cp\u003eStudent engagement discrepancies were identified using the difference between ME/C education program outreach and the education level at which interest in forensic pathology emerged (Figure 3). Based on survey responses, a larger proportion of students developed interest during middle and high school than to reported ME/C outreach targeted at those education levels. In contrast, more ME/C outreach was directed at undergraduate, graduate (non-medical), and medical students than interest emergence. Statistically significant differences between outreach and interest were noted at the high school, undergraduate, graduate (non-medical), and medical school education levels.\u003c/p\u003e\n\u003cp\u003eApproximately 20% of ME/C education programs reported participating in career days or professional job fairs (n = 33). Most programs participated in 1 to 3 guest speaking opportunities per year (46%, n = 75). Out of the 50 ME/C offices with internship programs, students participated in forensic/lab-based (64%, n = 32), investigative (64%, n = 32), public health (14%, n = 7), forensic anthropology (10%, n = 5), and administrative roles (10%, n = 5). Other reported internships involved forensic photography (n = 1) and toxicology (n = 1). Most ME/C education programs facilitating internships offered less than 5 positions per year (61%, n = 22).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEducational experiences offered by ME/C education programs consisted primarily of hands-on experiences (83%, n = 87), didactic lectures (70%, n = 74), and job shadowing (60%, n = 63). Fewer offices facilitated textbook reading assignments (39%, n = 41). small group discussions (38%, n = 40), quizzes and exams (18%, n = 19), journal club (16%, n = 17), and guest speakers (10%, n = 11). Programs allowed students to observe at autopsy (96%, n = 115), attend didactic lectures (73%, n = 88), eviscerate and record organ weights (71%, n = 85), participate in dissection (68%, n = 82), attend court testimony (68%, n = 81), attend scene investigations (59%, n = 71), perform research (38%, n = 46), attend meetings with law enforcement and attorneys (30%, n = 36), log and photograph evidence (23%, n = 27), attend meetings with decedent families (15%, n = 18), perform toxicology screens (14%, n = 17), and complete data requests (13%, n = 16). Other activities included participation in case conferences (n = 4) and fatality reviews (n = 1). In addition to attending meetings with related professions, interdisciplinary exposure was most often facilitated via tours and job shadowing. Out of the 43% of ME/C education programs offering dedicated interdisciplinary exposure (n = 70), this included shadowing death investigators (84%, n = 59), forensic anthropologists (34%, n = 24), toxicologists (27%, n = 19), crime laboratory scientists (24%, n = 17), histologists (16%, n = 11), district attorneys (9%, n = 6), public defenders (6%, n = 4), and organ procurement agencies (1%, n = 1).\u003c/p\u003e\n\u003cp\u003eDuring the completion of undergraduate coursework, 50% of participants designated biology and/or medical science as their primary field of study (n = 134) (Figure 4). This included sub-categories within biology, such as microbiology (n = 4), zoology (n = 2), and entomology (n = 1). Participants also studied chemistry (13%, n = 35), biochemistry (6%, n = 16), psychology (8%, n = 21), anthropology (6%, n = 15), criminal justice (2%, n = 5), public health (1%, n = 4), neuroscience (1%, n = 3), business administration and management (including advertising and finance) (1%, n = 3), and computer and information sciences (\u0026lt;1%, n = 1). Other fields of study included foreign language (n = 9), forensic science (n = 8), religion (n = 4), engineering (n = 3), mathematics (n = 3), physics (n = 3), exercise science and physiology (n = 2), nutrition science (n = 1), and computer science (n = 1). Prior to attending medical school, 24% of participants pursued a graduate degree, with most designating biology and medical science as their fields of study (33%, n = 19). Additional graduate (non-medical) fields of study included public health (14%, n = 8), forensic science and medicine (9%, n = 5), neuroscience (7%, n = 4), chemistry (4%, n = 2), and anthropology (4%, n = 2). Other graduate fields of study were pathology (n = 4), law (n = 4), pathologists\u0026rsquo; assistant (n = 1), anatomy (n = 1), physician assistant (n = 1), education (n = 1), biomechanics (n = 1), exercise physiology (n = 1), and foreign language (n = 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants considered a mean of 1.9 non-pathology specialties during their education and training before selecting forensic pathology as a career choice (\u003cem\u003eSD\u003c/em\u003e = 1.5). Family medicine (23%, n = 60), emergency medicine (19%, n = 50), internal medicine (18%, n = 47), surgery (18%, n = 46), psychiatry (17%, n = 43), radiology (15%, n = 40), and obstetrics and gynecology (13%, n = 34) were most common. Other specialties considered included orthopedics (n = 18), anesthesiology (n = 16), dermatology (n = 15), critical care (n = 8), geriatric medicine (n = 3), neurology (n = 13), oncology (n = 11), ophthalmology (n = 9), otolaryngology (n = 6), urology (n = 5), cardiology (n = 3), nephrology (n = 3), infectious disease (n = 1), palliative care (n = 1), nuclear medicine (n = 1), and physical medicine and rehabilitation (n = 1). Interestingly, 24 participants exclusively considered forensic pathology during their education and training, while only 8 participants indicated that they considered non-forensic pathology.\u003cbr\u003e\u0026nbsp;Factors that were most influential to participant interest in forensic pathology included rotations during residency (54%, n = 142), the influence of a professor or mentor (49%, n = 128), rotations during medical school (41%, n = 108), shadowing a forensic pathologist (37%, n = 98), reading books (32%, n = 84), and meeting someone in the field (31%, n = 82). Hearing lectures (28%, n = 74), watching television shows and movies (24%, n = 64), previous work experience (12%, n = 32), volunteering (10%, n = 26), and the influence of peers (8%, n = 20) were also contributory. Participants that indicated their previous work experience contributed to their interest have held positions as autopsy technicians (19%, n = 6), death investigators (9%, n = 3), pathology researchers (9%, n = 3), pathologists\u0026rsquo; assistants (6%, n = 2), anatomical dissectors and diners (6%, n = 2), and medical examiner\u0026rsquo;s office security (3%, n = 1). Some participants also indicated that they had experience in funeral service (6%, n = 2), organ and tissue recovery (6%, n = 2), and nursing (3%, n = 1). Other factors consisted of life experiences (n = 8), learning experiences during other education levels (n = 5), reading newspapers or websites (n = 3), internet searches (n = 1), and a lack of other specialty options for international medical graduates to practice in the U.S. (n = 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eJob satisfaction associated with a career choice in forensic pathology was overwhelmingly positive, with most participants indicating that they strongly agreed, somewhat agreed, or agreed with key factors impacting specialty choice (Figure 5). Participants considered forensic pathology to be intellectually challenging (95%, n = 202) and exciting/rewarding (90%, n = 195). They were satisfied with their decision to pursue a career in the field (92%, n = 192), their lifestyle (83%, n = 179), and their income (72%, n = 155). Additionally, they felt they had sufficient opportunities for social interaction (76%, n = 166). In contrast, only 27% felt that they received sufficient exposure to the field in medical school (n = 57) and 25% considered the perception of the field as a specialty choice as positive (n = 56).\u003c/p\u003e\n\u003cp\u003eOf the 271 individual respondents, 43% reported participating in a pathology student interest group while in medical school (n = 116). In contrast, only 30% of ME/C education programs collaborated with pathology student interest groups to promote available student rotations and engage in outreach efforts (40%, n = 34). Additional strategies employed to connect with students included utilizing academic institution websites (52%, n = 45), listing rotations on the ME/C office website (30%, n = 26), using an online rotation database such as the NAME International Training Organization Database or Association of American Medical College Visiting Student Learning Opportunities\u003csup\u003e\u0026trade;\u003c/sup\u003e (17%, n = 15), participating in career days (14%, n = 12), posting on online recruiting platforms such as Handshake (5%, n = 4), or social media (2%, n = 2). Several participants indicated that their organization does not advertise (n = 6) or coordinates student rotations directly with an academic institution (n = 6).\u003c/p\u003e\n\u003cp\u003eMany ME/C education programs identified the quantity of workload (65%, n = 60), adequate staffing (52%, n = 49), and physical office space (52%, n = 48) as the greatest barriers to implementing and facilitating student rotations. Staff motivation (40%, n = 37), distribution of workload (33%, n = 31), legal/liability (33%, n = 31), funding (33%, n = 31), lack of academic institution response (23%, n = 21), and digital competence (3%, n = 3) were also contributory. Other factors included lack of stakeholder support (n = 5) and absence of student/trainee engagement (n = 2). Of the 163 ME/C education programs, 17% provided suggestions on how educational initiatives can be supported at their office in the future (n = 27). Themes included the development of an educational toolkit containing curriculum models, online modules, open access learning materials (e.g., lectures, slides, media, clinical cases), a user-friendly database for educational opportunities, stakeholder outreach materials, and stipends for internships and away rotations.\u003c/p\u003e"},{"header":"IV. Discussion","content":"\u003cp\u003eThis study demonstrates that forensic pathology is beginning to see an influx of interest developing earlier in the medical education timeline from non-traditional pre-medical majors, alternate career paths, and other medical specialties. Presently, these groups are not a substantial target of ME/C educational outreach. Further, discrepancies exist between existing outreach efforts and the educational levels at which interest is emerging in forensic pathology. Taken together, these findings suggest that more complex factors are contributing to demographic shifts within the forensic pathology workforce and that student exposure through innovative, unconventional routes is necessary to address the workforce shortage. Multiple avenues exist to reach these groups of prospective recruits. Potential opportunities include: 1) facilitating rotations to a more diverse student and interprofessional population; 2) increasing community engagement (e.g., open-access lecture series and social media); 3) strengthening clinical and academic affiliations (e.g., curriculum-relevant didactics, student/trainee shadowing and rotations, and interdisciplinary research); and 4) empowering ME/C education program outreach with resources and support.\u003csup\u003e22\u003c/sup\u003e\u003cbr\u003e\u0026nbsp;\u003cbr\u003eOverall, lifestyle and job satisfaction measures for forensic pathologists in this study were comparable to many of the happiest specialties in medicine, such as pediatric medicine, dermatology, and ophthalmology.\u003csup\u003e23-25\u003c/sup\u003e Conversely, the recorded responses reflect that the perception of forensic pathology as a viable career choice in medicine remains enduringly negative, potentially due to widely held misconceptions that forensic pathology lacks opportunities for social interaction, intellectual challenge, and professional fulfillment.\u003csup\u003e14-15,26\u003c/sup\u003e With the vast majority of respondents indicating that they find their career rewarding and have sufficient opportunities for social interaction (i.e., through meaningful interactions with decedents\u0026rsquo; families, providing expert court testimony, and collaborating with the medicolegal community), the findings of this study directly dispute these misperceptions. Further, participants felt they did not receive sufficient exposure during medical school. Existing research emphasizes the importance of optimizing curricular design to increase student specialty exposure during the preclinical years.\u003csup\u003e11\u003c/sup\u003e However, with 70% of allopathic medical schools utilizing an integrated, systems-based core curriculum, schools are unlikely to incorporate subspecialty-specific lectures into an already rigorous curriculum.\u003csup\u003e27\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePotential solutions to addressing a lack of curricular integration before residency may involve increasing the total number of faculty appointments and affiliation agreements between ME/C offices and academic institutions. This framework can promote didactic collaboration and experiential learning opportunities, thereby strengthening the development of an educational pipeline for students who may be interested in forensic pathology. Currently, 71% of medical school-based pathology departments offer faculty appointments to forensic pathologists at affiliated offices.\u003csup\u003e28\u003c/sup\u003e Similar agreements are often available through undergraduate and graduate (non-medical) programs, however, this study found that only 5% of ME/C offices are affiliated with an academic institution. Affiliations are beneficial because they permit ME/C offices access to potential funding, equipment, professional development resources, and new opportunities for student engagement (i.e., curricular inclusion via preclinical lectures). Preclinical didactic lectures developed by forensic pathologists on curriculum-related and board-relevant topics can provide subspecialty access for students, improve institutional receptiveness, and demonstrate the clinical applicability and interdisciplinary relevance of forensic pathology. While delivering lecture content, an affiliated forensic pathologist can promote forensic pathology as a career choice and advocate for shadowing, rotations, or active learning opportunities in ME/C offices, thereby cultivating interest and increasing awareness of forensic pathology. This study reinforces that early engagement through these methods with follow-up rotation opportunities is critical to securing student specialization. However, 52% of medical schools are not affiliated with a ME/C office. The students at these schools are likely unable to experience forensic pathology in a practical setting until their fourth year of medical school, when they gain access to the AAMC Visiting Student Learning Opportunities (VSLO\u0026reg;) program. This is rapidly becoming too late to influence students in their career choice timeline. Fourth-year medical students primarily utilize VSLO\u0026reg; to secure \u0026ldquo;audition\u0026rdquo; rotations, where they are expected to have decided on a specialty and trial potential residency programs. For the 1.4% of U.S. medical students that match into a pathology residency, these rotations may or may not include forensic autopsy.\u003csup\u003e29\u003c/sup\u003e Considering the need for early specialty exposure, this leads to the question\u0026mdash; should existing ME/C education programs take on more academic affiliations to reach more students? Statistical analysis in this study indicated that ME/C offices with more affiliation agreements do not necessarily generate more forensic pathologists, suggesting that a quality-over-quantity approach is higher yield to combat the workforce shortage. Ultimately, the solution is not for existing ME/C education programs with limited resources to take on more affiliation agreements. As evidenced by this study, resource exhaustion and burnout need to be addressed prophylactically. Forensic casework and staff well-being take precedence, as these establish the foundation for program success. The solution to increasing student reach is two-fold: 1) ME/C offices without education programs need to be empowered with the appropriate resources to establish stable, high-quality outreach initiatives; and 2) existing ME/C education programs need to be supplemented with additional resources to capitalize on their success by refining their curriculum, collaborating and innovating with other disciplines, and helping guide the outreach efforts of ME/C offices seeking to establish new programs.\u003c/p\u003e\n\u003cp\u003eIn an ME/C setting, rotating students and trainees can be readily integrated into office workflow and trained to assist with a multitude of competency-matched entrustable professional activities at the discretion of the staff, parameters of the affiliation agreement, and insurance coverage. Potential activities include data entry, case digitization, quality assurance, data request completion, social media, public outreach, research, presentation preparation, evidence processing, specimen procurement, photography, and evisceration. This study established that fewer than half of current ME/C education programs are utilizing students and trainees in this capacity. From a learning perspective, the Accreditation Council for Graduate Medical Education emphasizes the need for graded, progressive responsibility in educational settings to promote professional development and autonomous practice.\u003csup\u003e30-31\u003c/sup\u003e Supplementing office operations with students and trainees serves the dual benefit of empowering staff and enhancing efficiency by allowing for the reallocation of staff work hours to more complex and larger-scale initiatives. After expanding their utilization of medical students and trainees, several ME/C offices included in this study increased their focus on innovative technology, grant procurement, community outreach, additional training, and other avenues for workforce development and retention. Broadly, policymakers and resource allocators tend to view this type of educational and innovative capacity as positive, which can further enhance office potential.\u003csup\u003e32\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eIn recent years, there has been a rise in collaboration between interdisciplinary professionals and ME/C offices. Disciplines such as forensic anthropology, radiology, molecular genetics, genealogy, entomology, and epidemiology are becoming increasingly utilized in a medicolegal setting.\u003csup\u003e33-39\u003c/sup\u003e Additionally, growing numbers of forensic pathologists are entering the workforce with other subspecialty training. At the time of this study, 16% of incoming forensic pathology fellows have completed additional fellowships in pediatric pathology or neuropathology.\u003csup\u003e40\u003c/sup\u003e This study identified a variety of interdisciplinary fields with the potential to strengthen pipeline diversity and provide alternative avenues for recruitment. Notably, respondents demonstrated a high prevalence of other specialty considerations during the educational and training timeline, as well as themes in undergraduate and graduate (non-medical) fields of study that apply to forensic medicine (i.e., chemistry, public health, neuroscience, anthropology). Engaging with students from these disciplines may serve the added benefit of addressing specific needs of individual ME/C offices in the form of entrustable professional activities. For example, many graduate (non-medical) students are required to produce a deliverable work product for the completion of their degree programs. Matching eligible students with pertinent interests to necessary projects offers creative opportunities that appeal to a broader population, resulting in a mutually beneficial relationship and the potential to produce an increasingly diverse and productive workforce.\u003c/p\u003e\n\u003cp\u003eThis study established that engagement barriers experienced by ME/C offices are primarily resource-oriented (i.e., quantity of workload, staffing, and physical office space). Many of the suggestions made by participants to support educational initiatives have the potential the reduce these barriers. However, funding opportunities for ME/C education are limited. Currently, these are primarily intended for forensic pathology fellowship programs or increasing training opportunities for existing forensic pathologists. For example, the Bureau of Justice Administration (BJA) Paul Coverdell Forensic Science Improvement Grant Program indirectly supports the education and training of forensic pathologists by improving the quality and timeliness of forensic services.\u003csup\u003e41\u003c/sup\u003e Similarly, the BJA Strengthening the Medical Examiner-Coroner System Program funds fellowships by providing up to $150,000 per fellow, which can be used for salary benefits, administrative costs, and up to $50,000 for student loan repayment.\u003csup\u003e42\u003c/sup\u003e While fellowship funding is critical to training competent forensic pathologists, only 41.7% of forensic pathology fellowship programs filled in the most recent Match cycle.\u003csup\u003e43\u003c/sup\u003e This is an 8.3% decrease from the preceding year.\u003csup\u003e44\u003c/sup\u003e The findings of this study suggest that expanding funding opportunities for a broader educational scope is necessary to increase the number of forensic pathology fellowship applicants and address the subspecialty workforce shortage.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study underscores the critical need for interdisciplinary collaboration in forensic pathology. The current workforce shortage necessitates comprehensive and sustainable educational strategies to cultivate a robust pipeline of future forensic pathologists, while broadly enhancing support and awareness of the field. Empowering ME/C offices to adopt strategic, innovative, and collaborative methods in medical education is pivotal to accomplish this. By providing ME/C offices with the necessary resources and support, we can overcome existing barriers, bolster the current workforce, and successfully engage the next generation of forensic pathologists.\u003c/p\u003e"},{"header":"V. Declarations","content":"\u003cp\u003eA. \u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e This study has been approved as category 2 exempt by the Institutional Review Board at Lincoln Memorial University-DeBusk College of Osteopathic Medicine (IRB00006284). Informed consent was obtained from participants during survey completion.\u003c/p\u003e\n\u003cp\u003eB. \u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003eC. \u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The datasets obtained during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eD. \u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eNone of the authors have a conflict of interest to disclose.\u003c/p\u003e\n\u003cp\u003eE. \u003cstrong\u003eFunding:\u003c/strong\u003e None.\u003c/p\u003e\n\u003cp\u003eF. \u003cstrong\u003eAuthor contributions:\u003c/strong\u003e JA: conceptualization, methodology, data curation, formal analysis, visualization, writing—original draft. MG: conceptualization, methodology, data curation, writing—original draft. EH: writing— review \u0026amp; editing. RQ: conceptualization, writing— review \u0026amp; editing, supervision. GP: conceptualization, visualization, writing—original draft. JF: writing—review \u0026amp; editing. LB: writing—review \u0026amp; editing. AK: formal analysis, writing—review \u0026amp; editing. MJM: conceptualization, writing— review \u0026amp; editing, supervision. GG: writing— review \u0026amp; editing. JG: conceptualization, methodology, data curation, writing—original draft, supervision. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eG. \u003cstrong\u003eAcknowledgements:\u003c/strong\u003e The authors wish to thank Brandi McCleskey, MD and the Board of Directors of the National Association of Medical Examiners for their support and dedication to workforce development in forensic pathology. We would like to thank Amanda McCoy for her assistance with data analysis during the preparation of this manuscript. We would also like to thank Rachel Geller, MD, Marquel Johnson, Julio Alicea, and Crystal Lee, MPH for their leadership and contributions to the establishment and growth of an innovative education program in DeKalb County, Georgia.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAmerican Association of Medical Colleges. The complexities of physician supply and demand: Projections from 2019 to 2034. 2021 Jun [cited 2024 Jan 10]. Available from: https://www.aamc.org/media/54681/download\u003c/li\u003e\n\u003cli\u003eWeedn VW. \u0026amp; Menendez MJ. Reclaiming the autopsy as the practice of medicine: A pathway to remediation of the forensic pathology workforce shortage. \u003cem\u003eAm J Forensic Med Pathol\u003c/em\u003e. 2020;41(4):242-248. doi: 10.1097PAF0000000000000589\u003c/li\u003e\n\u003cli\u003eCollins K. 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Available from: https://www.nrmp.org/wp-content/uploads/2023/05/Forensic-Pathology-MRS-Report-2023.pdf\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"forensic pathology, medical education, interdisciplinary, workforce, pipeline, career choice, pathways","lastPublishedDoi":"10.21203/rs.3.rs-5523141/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5523141/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eEarly engagement in medical education is critical to influencing career choice. Exacerbated by a rapidly accelerating specialization timeline, there is currently a national workforce shortage of forensic pathologists. This cross-sectional study explores the widespread challenges of recruiting and retaining trainees through a broad educational lens, addressing interdisciplinary factors associated with workforce pathways over time, academic affiliations, and underrecognized collaborative opportunities in medical examiner and coroner (ME/C) education programs. The purpose of this study is to perform a needs assessment of learners interested in forensic pathology and ME/C education programs in the United States.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eTwo different surveys were developed and distributed to 1) forensic pathologists and individuals pursuing a career in forensic pathology, and 2) ME/C education programs. Measures included factors associated with interest in forensic pathology and characteristics of ME/C education programs in the United States. Associations were analyzed using Pearson’s chi-square and Kendall’s tau-b.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe sample included 313 participants and 163 ME/C education programs. Interest in forensic pathology emerged during residency (27%), medical school (26%), and high school (24%), with increases occurring earlier in the education timeline from non-traditional pre-medical majors, careers, and medical subspecialties. Impactful career choice factors included rotations during medical school/residency and the influence of professors/mentors. ME/C education programs predominately targeted medical students (92%) and residents (76%) by providing opportunities for autopsy observation. Although 48% of medical schools are affiliated with an ME/C office, only 5% of ME/C offices are facilitating these experiences. There is no association between the number of affiliation agreements held by ME/C education programs and forensic pathologist output. Interdisciplinary exposure during rotations is primarily limited to job shadowing with death investigators. Quantity of workload (65%), staffing (52%), and office space (52%) are the greatest barriers experienced by ME/C education programs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThis study underscores the critical need for interdisciplinary collaboration and sustainable, innovative educational approaches to strategically engage future forensic pathologists. Proposed strategies include 1) facilitating rotations to a diverse student and interprofessional population; 2) increasing community engagement; 3) strengthening clinical and academic affiliations; and 4) empowering ME/C education programs with resources and support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number: \u003c/strong\u003eNot applicable\u003c/p\u003e","manuscriptTitle":"Career choice and interdisciplinary education in forensic pathology: A cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-11 06:51:03","doi":"10.21203/rs.3.rs-5523141/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-03-12T11:29:30+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-07T08:27:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-07T08:24:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2024-11-25T22:00:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"50766f80-5d8c-4d07-b8a1-483ce45f7450","owner":[],"postedDate":"March 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T16:05:33+00:00","versionOfRecord":{"articleIdentity":"rs-5523141","link":"https://doi.org/10.1186/s12909-026-09227-2","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2026-04-24 15:58:18","publishedOnDateReadable":"April 24th, 2026"},"versionCreatedAt":"2025-03-11 06:51:03","video":"","vorDoi":"10.1186/s12909-026-09227-2","vorDoiUrl":"https://doi.org/10.1186/s12909-026-09227-2","workflowStages":[]},"version":"v1","identity":"rs-5523141","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5523141","identity":"rs-5523141","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}