The first ten years of your career involves a lot of unlearning the dogmatic things you learned in medical school and fellowship.\u00a0 In training. we learn a *lot* of heuristics and rules of thumb.\u00a0 We learn about estimating time of death.\u00a0 We learn about patterns of injury.\u00a0 We learn about how to tell direction of fire from gunshot wounds.\u00a0 We learn how to weigh natural disease versus trauma in cause of death.\u00a0 And on and on.\u00a0 But what we are really learning are rules of thumb.\u00a0 A gunshot entrance wound is small and round.\u00a0 Except when it’s not.\u00a0 An exit wound is larger and stellate.\u00a0 Except when it’s “small and slit-like” or small and round.\u00a0 The biggest mistake that I see younger pathologists making is taking the rules they have learned in training and applying them as if they were the laws of God.\u00a0 They are not.\u00a0 One of the big keys of good forensic pathology practice is understanding the limitations of those kinds of determinations.<\/span><\/div>\n<\/div>\nHere’s a story about that.\u00a0 A few years ago, I consulted on a case where a man was tried for murder of his wife.\u00a0 His story was that he saw his wife in the morning, took the kids to school, and returned home to find her dead.\u00a0 He was charged with murder in large part (but not entirely) because his wife was in early rigor when he found her and a forensic pathologist said that it was impossible for early rigor to develop in an hour to an hour and a half.\u00a0 Of course, the ‘rule’ is that it takes 6-12 hours for rigor to develop, 6-12 hours for it to be stable, and 6-12 hours for it to go away.\u00a0 But that’s a rule of thumb.\u00a0 There are a thousand variables that change this.\u00a0 I’ve seen rigor start within fifteen minutes of death, and I’ve seen it delayed for days.\u00a0 The man was eventually acquitted, but only after two trials (the first was a hung jury) and months in jail.\u00a0 \u00a0 I’ve seen another forensic pathologist claim to be able to time an injury to within 30 minutes by evaluating the presence of inflammatory cells in a wound.\u00a0 I’ve seen a pathologist mistake decompositional change for a burn wound, which led to charges of murder and torture.\u00a0 And on and on.<\/p>\n
If you are a young pathologist, you need to observe these variations, and learn when these rules apply and when they don’t.\u00a0 A one or two year fellowship barely touches the surface. The best way to learn this is to work at a place that handles a lot of cases and where there are older pathologists who can act as mentors.\u00a0 And that means working at a ME office (public or private) where there is the time and inclination to mentor younger pathologists a bit. My experience is that you don’t get that kind of mentoring doing locum tenens work. If you go out on your own early in your career, you won’t have the benefit of this, and your chance of making a big mistake goes way up.\u00a0 You don’t want to make those kinds of mistakes ever, but you certainly don’t want to make them as a private consultant.<\/p>\n
My advice, for what it’s worth, is to start off a little more slowly.\u00a0 Work at a ME office and do some private work on the side.\u00a0 See if you like it, then make the jump. More, you might meet someone who has a similar interest and form a partnership during this time.<\/p>\n
It’s perfectly fine to do full time private work.\u00a0 But my personal opinion is that it’s better to get some experience under your belt first.<\/p>\n
Now let’s focus on what most people do when younger — work full time and do the occasional case on the side.<\/p>\n
First considerations:<\/strong><\/p>\nThe first three things you need to do are decide how much time you want to devote to this, you need to learn to say “no,” and you have to decide about what kind of cases you want to take — particularly whether or not you want to do private autopsies.<\/p>\n
The opportunities for this kind of work are huge, and once you start doing it, there’s a good chance you will be getting more opportunities than you can handle.\u00a0 This is particularly true if you are willing to work at indigent rates, because the public defender’s office will likely put you on a list and desperate public defenders will start calling.\u00a0 It turns out that I’m on lists that I didn’t even know existed,<\/p>\n
When you realize that every time you pick up the phone it’s an offer for a few thousand bucks, it’s hard to turn it down. You might feel that if you say “no,” then they’ll never call back again.\u00a0 Don’t worry.\u00a0 There are plenty of fish in the sea, and you need to make sure you don’t take on more than you can handle.\u00a0 Remember that you have a spouse and\/or kids or friends you want to go to the beach with or whatever.\u00a0 Don’t let this eat you up.\u00a0 So, decide how many cases you want to carry at any given time, and learn to say “no.”<\/p>\n
When deciding how many cases to carry, remember that even dormant cases can raise up and bite you.\u00a0 \u00a0I normally only carry two or three “active” cases at a time. But… dormant cases often take years.\u00a0 A common pattern is to have a flurry of activity early on — you look at the medical records, go over the autopsy and investigation findings, do the literature search, write a report, etc.\u00a0 Then you don’t hear anything for a year.\u00a0 Maybe the case is dead.\u00a0 Maybe not.\u00a0 Then a year later, they’ll call you and want you for a deposition on short notice.\u00a0 Then you don’t hear anything for another year, and — boom — they want you for trial in God-knows-where.\u00a0 \u00a0I got contacted a couple of weeks ago for two trials next month.\u00a0 Both were over four years old, and I hadn’t heard from anybody about them in almost two years.\u00a0 Then, suddenly, everybody wants me — -and *both* trials had been scheduled for the same week.\u00a0 I went from having an almost completely open month to having to juggle three trials, two of which were in conflict.<\/p>\n
The third thing to think about is whether or not you want to do private autopsies.\u00a0 I don’t.\u00a0 \u00a0In my entire career, I’ve done two private autopsies, both so-called “second autopsies.”\u00a0 Here’s the thing.\u00a0 The infrastructure cost for doing a non-autopsy private case is pretty minimal.\u00a0 You need a microscope, a way to search and get literature, a place to sit, and time.\u00a0 If you are going to do an autopsy, you need to arrange a location, histology, toxicology, ancillary testing, etc.\u00a0 \u00a0Maybe it’s just me, but I’m not a fan of doing gross-only autopsies.\u00a0 I’ve seen people have issues with getting tox paid for, etc. Because of the logistics problem, a lot of the second autopsies I’ve seen have been a little incomplete.\u00a0 I don’t like doing autopsies in funeral homes.\u00a0 And on and on.<\/p>\n
I know there are people who *love* doing private autopsies.\u00a0 And, you can charge a lot for them.\u00a0 But they are not my cup of tea.\u00a0 I hope that folk who like to do private autopsies either comment here or on one of the mailinglists.<\/p>\n
Finally, when it comes to case mix, you may well eventually specialize in certain kinds of cases.\u00a0 I’ll write about that later, but early on, you probably want to experience as many different kinds of cases as you can. So don’t specialize early on. It will make you a better consultant and, more important, a better Medical Examiner in your day work if you get broad experience.\u00a0 Later, you may want to specialize, but my personal opinion is that you shouldn’t limit yourself too much early on.<\/p>\n
So, now you know what kind of commitment to make, and you are ready to start.\u00a0 How do you get your first cases?<\/p>\n
Referrals:<\/strong><\/p>\nYou don’t need to advertise.\u00a0 You don’t need the million dollar web presence.\u00a0 You don’t need to splash all over social media.\u00a0 Just talk to your friends.<\/p>\n
Everybody who does this at the sideline level gets more requests for help than they can handle.\u00a0 I don’t advertise.\u00a0 I don’t push my service in any way.\u00a0 But\u00a0 I get three or four pings from lawyers a month.\u00a0 I usually turn down three of the four.\u00a0 I welcome the calls, and I appreciate the referrals I get from colleagues, because there’s a lot of kinds of cases I just don’t want to take, and this allows me to be a little selective in the cases I accept.\u00a0 But I refer most cases on to someone else, just like many of them were referred to me.<\/p>\n
Because most of us only accept a portion of the cases we offered, the lawyers who call us are extremely grateful if we can point them to someone else.\u00a0 I have a list of a handful of colleagues that I routinely send out when I decline a case.\u00a0 I have two lists, actually. I have one list of folk in my region.\u00a0 Some places put restrictions on out of state or out of region experts, especially if the state is paying for it.\u00a0 I used to get a lot of calls from California, for instance, but don’t any more.\u00a0 I sent an email to ask why, because I was concerned that I had screwed up somewhere.\u00a0 They told me that, no, they were happy with my work, but they had received guidance that the jurisdiction would not pay for interstate travel.\u00a0 I have another, broader, list for folk without those restrictions.<\/p>\n
If you are thinking about doing private cases, that almost certainly means that you are working at a place that is friendly to it.\u00a0 That, in turn, suggests that some of your colleagues are also doing private work.\u00a0 Ask them for referrals.\u00a0 The same thing is true for nearby offices.\u00a0 Talk to your colleagues in the next county or regional office. Talk to your colleagues from fellowship.\u00a0 Talk to your friends when you have drinks with them at the next NAME or AAFS or regional FP meeting.\u00a0 You should very quickly start getting the occasional referral.<\/p>\n
Don’t worry if it takes awhile.\u00a0 There are months when I *don’t* get those three or four cases I turn down.\u00a0 Some cases I might not think are appropriate for a younger pathologist — some cases are frankly pretty risky to take.\u00a0 But they will come.\u00a0 \u00a0Once you get one case and do a decent job, the lawyer you worked for will tell his or her friends.\u00a0 And you are on your way.<\/p>\n
Work with lawyers, not private individuals:<\/strong><\/p>\nSome folk get all excited about getting an online presence.\u00a0 They plant flags in social media.\u00a0 They put up a web page. They advertise with expert witness referral services.\u00a0 Etc. etc.\u00a0 \u00a0All of that is fine (except perhaps the referral service, but I’ll talk about that later).\u00a0 \u00a0I don’t do any of that.\u00a0 I have a blog, obviously, but I don’t focus that on getting business.\u00a0 What I’ve discovered is that the more I’m “out there,” the more likely I am to get cases I don’t want to take.\u00a0 If you are doing this full time and are trying to bring in all the possible business you can, that’s one thing.\u00a0 But if you are just doing this as a sideline, you will be turning down cases soon enough anyway.<\/p>\n
My experience is that if you are out there in public-facing media, you are a *lot* more likely to get contacted by families, plaintiffs, and defendants directly.\u00a0 That can be a problem.<\/p>\n
Here’s a big piece of advice:<\/p>\n
Starting off, do *not* deal directly with non-lawyers.\u00a0 \u00a0A family member who is expert-searching is often searching for a particular outcome, not expertise.\u00a0 When they cut you a check, they think they are buying someone to testify in their favor, regardless of what your conclusion is.\u00a0 I’ve had family members convinced that their terminally-ill relative was neglected, abused, or “murdered,” and when I came to the conclusion that the decedent just died of her disease, they were furious and refused to pay.\u00a0 Families don’t know how court really works.\u00a0 They don’t know what is and is not acceptable behavior. It can be a huge hassle.\u00a0 When I get a call from a defendant or family member or someone wanting to sue a hospital, I always tell them to have their lawyer call me.\u00a0 I try only to deal with counsel.<\/p>\n
Don’t get me wrong, I *have* taken cases directly from individuals.\u00a0 And I know a couple of people who do a fair number of private autopsies for medical malpractice cases.\u00a0 But those cases, for me, have much more often been problem cases.<\/p>\n
Next installment:\u00a0 \u00a0Insurance and incorporation<\/p>\n
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