"The work of a forensic pathologist is not for the faint of heart. We deal with death and violence every day, and the toll it takes on our mental and emotional health cannot be underestimated." - Dr. Kathy Reichs
Occupational health is an indispensable aspect of workplace safety and worker well-being. Forensic pathology practice poses significant physical, chemical, biological, and psychosocial hazards, including exposure to infectious diseases, hazardous substances, long working hours, and stressful conditions. It is essential for forensic pathologists to understand and minimize their exposure to these risks to ensure the effective and safe performance of their duties while protecting their health and that of others.
This short communication highlights the unique occupational safety and health issues faced by forensic pathologists in India, including psychosocial hazards, occupational burnout, and violence against forensic pathologists, which require further research. By addressing these issues, forensic pathologists can improve their overall occupational health, reduce the risk of adverse health effects, and ensure the safe and effective performance of their critical work. There is enough research on the traditional hazards faced by autopsy surgeons in international and Indian contexts.1, 2, 3
Forensic pathologists face several psychosocial hazards in their work because of exposure to stressful and traumatic work environments, such as post-mortem examinations or the handling of mortal remains. They are generally prone to reel under tremendous emotional stress because of working in close proximity to violent crimes against the human body. There is a high degree of burnout, secondary traumatic stress, and compassion fatigue among crime pathologists caused by continuous exposure to death and suffering. The emotionally demanding and physically isolating nature of their work along with perpetual ethical dilemmas at the job can predispose pathologists to moral distress, depression, anxiety, or other mental health issues.
In 2002, the first study on this subject was conducted in the Netherlands involving 132 forensic pathologists, which found that 76.3% of them had experienced at least one traumatic event at work in the previous year. Approximately 14% of the participants reported experiencing distressing symptoms. The traumatic events reported included performing autopsies on children, suicide victims, or decomposed bodies, as well as examining aggressive patients. About a quarter of the physicians sought psychological or psychiatric consultation, or even psychotherapy, due to work-related stress. In terms of burnout, 25% of physicians showed a prominent level of emotional exhaustion, 40.5% exhibited signs of depersonalization, and 20.2% had low levels of personal accomplishment, as indicated by the Maslach Burnout Inventory (MBI) questionnaire.4
A chronological narrative review on this subject also indicated a strong need for more studies amongst forensic pathologists to identify etiopathogenic factors of burnout to prevent the evolution of mild signs and symptoms into severe mental illness. The authors also stressed the factor that burnout is generally cumulative and stress mounts up incrementally which must be managed on a dynamic basis by employing a proper risk assessment approach. It is always better to be safe in dealing with mental health than to be sorry at a later date.4
In another study conducted at a mortuary in Turkey using standardized questionnaires to assess mental health symptoms, like Maslach Burnout Inventory (MBI) and Post-traumatic Symptom Screening Scale, some interesting findings were reported. Forensic Medicine specialists were found to be at high risk to develop burnout and post-traumatic stress disorder. The autopsy technicians presented with more emotional exhaustion and post-traumatic stress disorder symptoms whereas resident doctors presented with a lower sense of personal accomplishment.5
A similar study was conducted among forensic physicians in Egypt using Maslach Burnout Inventory, and the Brief COPE Inventory to study both burnout and coping strategies. The forensic physicians scored moderate to high burnout in the emotional exhaustion, depersonalization, and personal accomplishment subscales. It was also established in this study that facing more than five stressful duties in a calendar month is one of the crucial factors in burnout. The most common strategy adopted by autopsy surgeons to fight burnout was adaptive coping according to the study.6
In another related study conducted among forensic medicine practitioners using MBI in Romania, the participants scored lower in the emotional exhaustion subdomain and medium scores in the depersonalization and personal accomplishment subdomains. A third of the participants faced some or other emotional abuse from the relatives of their patients/cases and sought professional psychiatric/ psychological help.7
It was also openly put forward by several forensic pathologists that, the grief of dealing with dead and aggressive patients accumulates over a period and can surface later affecting their personal lives. The magnitude of psychological trauma was more while dealing with pediatric cases and mass casualties. The concept of vicarious traumatization is true in the case of crime pathologists as they re-live the trauma day in and day out.8
Burnout among medical practitioners, particularly forensic pathologists, is a topic that receives limited attention in India. We are all aware of the heightened violence against doctors across the globe and in our country, which is also a strong reason for mounting stress amongst medical practitioners in discharging their duties. Nonetheless, for every forensic pathologist in this country, performing her best in a resource-limited setting is itself a big mental challenge. Sometimes, there is a dialectical discordance between the acumen of the forensic pathologist and the availability of infrastructure for living up to her dream to know the exact cause of death. But, despite all shortcomings, she strives hard to do their best in arriving at a scientific conclusion regarding the task at hand.
Some of the wicked problems responsible for mental stress for a forensic pathologist in our country include improperly crafted intersectoral coordination procedures with different departments like police, judiciary, and municipal authorities. The procedural flaws of police in dealing with medicolegal matters, the reluctance of the judiciary in accepting complete virtual evidence deposition, and the complacency of municipal authorities in the disposal of unclaimed dead bodies are some examples worth mentioning that annoy an autopsy surgeon now and then. Moreover, instances of verbal and physical abuse of doctors dealing with medico-legal work for no fault of theirs is commonplace in India considering the quite widespread resistance to an autopsy coupled with a lack of awareness of the need for a post-mortem examination amongst the next of kin of the deceased. It is even worrisome to note that the knowledge of the general public about autopsy procedures is abysmally minimal causing many issues for autopsy surgeons.
It is high time we conduct similar kinds of cross-sectional studies using MBI-like tools in Forensic Medicine departments of every tertiary care hospital in India to properly come up with a problem statement pertaining to psychosocial hazards which requires our concerted attention to deal with. There is a strong need for psychoeducation and psychological support services in forensic settings. There is also an obligation on our part to scientifically quantify the whole gamut of hazards in forensic practice to establish the rationale for risk allowance for medico-legal practitioners.
Bickering among professionals in the field of forensic medicine can have detrimental effects, leading to unnecessary stress and ultimately contributing to burnout among practitioners. It is essential to address this issue to safeguard the well-being of forensic medicine professionals. To combat burnout and promote a healthy work environment, it is crucial to establish mechanisms for self-regulation and adherence to scientific and ethical codes of practice. By enforcing professional guidelines and standards, we can reduce conflicts and promote collaboration based on mutual respect and trust. Moreover, investing in infrastructure improvement, particularly in mortuaries, is imperative to ensure optimal working conditions and minimize stressors. Additionally, implementing quality improvement programs and seeking accreditation can enhance the overall quality control and assurance in forensic medicine
A multifaceted approach is necessary to address the psychosocial hazards faced by forensic pathology practitioners, which includes both proactive measures and responsive support. This approach may involve providing appropriate training and education on coping mechanisms, stress management, and emotional resilience. It also involves encouraging a positive work environment that supports open communication, collaboration, and teamwork. Furthermore, it is important to limit the number of medico-legal cases per pathologist and develop a scale to categorize overload to address the challenge of overburdening at work.
To minimize the negative impacts of traumatic cases on practitioners, an initiative-taking approach is necessary. In addition to implementing risk assessment and management strategies to minimize exposure to traumatic events, governments should promote self-care and work-life balance, provide professional development opportunities, and encourage forensic pathologists to share their experiences in a safe and supportive environment. By doing so, we can help promote the overall well-being of forensic pathologists.
In India, the issue of case overload in the criminal justice system at the police, prosecution, and judiciary levels is often highlighted in popular media and discussions. However, the overburdened life of a forensic pathologist is rarely acknowledged, and their exemplary services are often denied recognition. In some situations, forensic surgeons are stereotyped and identified with a lot of negative things because of the nature of the work they do, leading to low self-esteem, ostracization, and less social life for forensic pathologists. Such negative attitudes can create a stigma around being a forensic pathologist also.
It is essential to appreciate and recognize the contributions of forensic pathologists to society. In this regard, it would be beneficial to have a national day/week to explain the importance of forensic pathology to the general public in India. The IAFM (Indian Academy of Forensic Medicine) after due deliberation and consultation with professional members came up with the idea of celebrating May 12 of every year as Forensic Medicine Day. This is a welcome move under prevailing circumstances. In the coming days, the professional body should release the theme of the day every year to have a focussed approach to build the social profile and public image of the department as a whole.
For example, the National Association of Medical Examiners (NAME) celebrates Medical Examiner week in the first week of October to highlight the significance of a crime pathologist in the United States.9 The Royal College of Pathologists also celebrates Pathology awareness week every year in June.10 These initiatives can help promote a better understanding of forensic pathology and recognize the critical role that forensic pathologists play in the criminal justice system.
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