Forensic Emergency Medicine Niche
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Forensic Emergency Medicine Niche

Authors

Spencer Lord, MD
Emergency Medicine Resident
Albany Medical Center

Kyle Ackerman, MSII
Howard University College of Medicine

Faculty Editor

Heather V. Rozzi, MD, FACEP
Medical Director, Forensic Examiner Team
Department of Emergency Medicine
Wellspan York Hospital

Special thanks to our 1st edition author

Krystle Shafer, MD

INTRODUCTION

Description of the specialty
Emergency physicians care for patients with forensically relevant chief complaints nearly every shift. Victims of trauma including gunshots, stab wounds, motor vehicle crashes, and sexual assault pass through the ED daily. Emergency physicians are in the ideal position to identify victims of domestic violence, elder mistreatment, child abuse, and human trafficking. In all of these cases, they may be required to collect and preserve evidence, provide detailed documentation, provide court testimony, and refer to the appropriate agencies. Thus, it is important for EM physicians to be appropriately trained and have access to the necessary resources to care for this unique population of patients. 

History of the specialty/pathway
In recent decades, violent crime, abuse, assault, and neglect have risen to arguably epidemic levels. EM physicians are frequently involved in the identification, evaluation, and treatment of these patients. In response, the Department of Emergency Medicine at the University of Louisville established the first forensic medicine fellowship in the U.S. in 1991. By 2006, ACEP established the Forensic Medicine Section. Very few residencies include clinical forensic medicine in their training curricula, but ACEP’s Model of Emergency Medicine does require proficiency in sexual assault training. Fellowships within this field have also been slow to develop. There are forensic preceptorships available, but they are often under the auspices of other specialty organizations, such as the Child Abuse Preceptorship offered by the Pennsylvania Chapter of the American Academy of Pediatrics.

Why residents choose this career path
Residents follow this career path when they have a strong interest in utilizing the forensic education and skill set to assist victims of crime, injury and violence. Physicians in this field may have a leading role in violence prevention and in the care of victims of trauma and violent and sexual crime. 

How do I know if this path is right for me?
Do you find yourself interested in becoming better at forensic medical evaluation, injury documentation, and photography? Do you want to become a champion for victims and an expert at testifying for these patients? Are you interested in helping with the forensic training and education of health care providers? Do you desire to become an expert and leader in this field within your hospital system?  If you answered yes to any of these questions, you should strongly consider a career in clinical forensic medicine. 

Career options after residency
Some options to consider when designing a career with a focus on forensic emergency medicine include:

  • Employment with a Sexual Assault Response Center
  • Employment with a Child Advocacy Center (CAC)
  • Director of Forensics within departments of emergency medicine
  • Researcher in forensic relevant topics
  • Forensics educator of residents, nurses, and other providers
  • Local and national speaking engagements 

Splitting time between departments
Most clinicians interested in emergency forensics will develop this niche within their own EDs and will not split time. Some physicians may be double board certified in another specialty or perhaps have a second career, such as police officer, etc., and then will split time between departments. Others may consider working in an ED and a CAC or Sexual Assault Response Center. The key is to avoid “double-booking” and difficult transitions, such as going from an overnight ED shift directly into a day shift working at a CAC. This will need to be carefully negotiated in your initial contract. You will also need to negotiate vacations and holidays. Finally, don’t forget to negotiate your involvement in activities such as departmental meetings, hospital committees, etc. Ideally, you would have fewer hospital commitments to accommodate your forensic involvement. 

Academic vs. community positions
Those interested in teaching and/or research often gravitate towards academia or community-based academic positions. However, those with an interest in pediatric forensics may find academic positions challenging, as large centers often separate their adult and pediatric patients into separate emergency departments. Another consideration is whether the hospital is a designated center for sexual assault forensic examination (SAFE). It is not uncommon for an entire county to bring all sexual assault cases to one designated hospital. Finally, one should consider the department’s current involvement in forensic emergency medicine and their openness to hiring someone (you) to specialize in this niche. 

IN-DEPTH SPECIALTY INFORMATION

Number of programs
There are currently no ACGME-accredited forensic fellowship programs. There are academic emergency medicine programs that house forensic departments. Currently the training and track are more of a “niche” within emergency medicine. Therefore, it is important to contact program directors to discuss the scope of their program’s forensic training and department resources. 

Preparing for a Career in Forensics Research requirements
There is no research requirement to become involved in this field. Because clinical forensic medicine is a young field, research opportunities abound, and it can illustrate your interest in the niche. 

Suggested rotations to take during residency
Rotations to consider: violence prevention programs, coroner's office, forensic toxicology service, Child Advocacy Centers, child abuse service (offered within pediatrics in some academic institutions), medical examiner's office, detention center clinic, and hospital-based forensic examiner teams. 

Suggestions on how to excel during these elective rotations
Demonstrate your dedication, interest, and knowledge base. Read every day about relevant topics. It is always a good idea to arrive early and stay late if needed, especially to ensure all patient care has been completed. Be courteous to everyone you encounter. 

Should I complete an away rotation?
If your department does not provide you with a rotation and/or exposure to a particular patient population that you desire (example: child abuse cases, elder abuse, sexual assault, etc.) then we highly encourage you to seek away elective opportunities. We encourage you to seek out programs that have forensic departments within their department (such as Drexel University College of Medicine) or at least EDs that are the designated center for assault/abuse, etc., cases in their regions. 

How can I make my CV stand out from the crowd?
Your resume should clearly display your interest in forensics by listing multiple supporting activities. Strive for leadership positions where you have meaningful involvement. It might be helpful to narrow your niche even more within forensics (such as child abuse, for example). Seek training through conferences, workshops and online training modules to better educate yourself and then subsequently educate others about your niche. Online training modules on multiple forensic topics are available through ACEP’s online continuing medical education repository. Seek training through conferences, workshops and online training modules to better educate yourself and then subsequently educate others about your niche. Learn the administrative skills that are needed to design and manage a forensic examiner team. 

Should I join a hospital committee?
Many hospitals have a committee that reviews child abuse and neglect reports, elder abuse reports, sexual assault cases, domestic violence cases, etc. It would be wise to inquire about such committees and to join if possible. Ideally your involvement in this committee would be meaningful and active. 

Publications other than research
This is highly encouraged! There are many opportunities for submitting articles in medical newsletters, magazines, journals, and blogs. You could also consider working on a podcast. This is an excellent opportunity to expand your own and the audience’s knowledge base on a particular topic and also to bolster your writing skills. Perhaps the best way to accomplish this is to reach out to your targeted publisher. You will be surprised by how many doors open simply by asking!

Textbooks to consider reading

  • Curry, Merlin. Rosen's Emergency Medicine: Concepts and Clinical Practice, 9th ed, Elsevier, 2018
  • Olshaker J, Jackson M, Smock W. Forensic Emergency Medicine. Philadelphia, PA: Wolters Kluwer; 2006.
  • Layne-James. Simpson’s Forensic Medicine, 13th ed. Taylor & Francis Group, 2014
  • Riviello RJ. (Ed). Manual of Forensic Emergency Medicine: A Guide for Clinicians. India: Jones & Bartlett; 2009.
  • American Academy of Pediatrics. Visual Diagnosis of Child Abuse on CD-ROM. American Academy of Pediatrics, 2003.

Important skills to practice during residency to prepare for a career in Forensics

  • Broaden your knowledge base in forensics:
    • Learn the different burn and fracture patterns associated with child abuse.
    • Understand how to appropriately document and photograph child abuse findings.
    • Learn the verbal and physical clues that will alert you to elder abuse, domestic violence, and human trafficking victims.
    • Understand the concept of chain of custody and preservation of evidence.
    • Become proficient at the sexual assault exam.
  • Develop leadership and administrative skills to run forensic medicine sections of an emergency department.
  • Develop effective educational skills to teach others about forensic medicine.
  • Expand your knowledge about the legal system and learn about court testimony.
  • Understand the protocols to appropriately identify and assist potential human trafficking victims.
  • Recognize the specific detail and documentation necessary for the admissibility of chart entries in legal proceedings.

Creating a Career in Forensics: Convincing Your Employer
How do I stand out from the crowd in the interview/hiring process?
Your goal during the interview is to be engaging, confident, and personable. Be courteous to everyone you meet, and treat every event/interaction as part of the interview. Make sure your application is complete and you fulfill all requirements in a timely manner. Communicate a clear vision about how your future career will include forensics.

What types of questions are typically asked?

  • What are your 5- and 10-year career plans?
  • What specifically was your forensic training during residency?
  • How do you plan to expand our department’s involvement and education in forensic medicine?
  • What are your strengths and weaknesses?
  • Tell me more about [fill-in-the-blank] leadership opportunity that you list here on your resume.
  • Why do you seek employment at our institution?

How many recommendations should I get? Who should write these recommendations?
Each potential future employer will have its own policies regarding the number of recommendations required. Seek letters from physicians who know you well and will advocate strongly for you. Letters from program directors and/or department chairs would be favorable. If you have a mentor within the niche of forensics, a letter from him or her would be ideal. Letters that display your knowledge of and competence in forensic emergency medicine will help support your cause for a career that allows you to continue to build and expand upon your forensic training.

CONCLUSION

Additional resources

Journals

  • Journal of Forensic Sciences
  • Journal of Forensic and Legal Medicine
  • The American Journal of Forensic Medicine and Pathology
  • Journal of Forensic Medicine
  • Global Journal of Nursing & Forensic Studies
  • Medical Toxicology and Clinical Forensic Medicine Journal
  • Journal of Forensic Toxicology and Pharmacology

Journal articles

  • Ryan M. Clinical Forensic Medicine. Ann Emerg Med. 2000;36(3):271-273.
  • Finn R. Tips for Conducting a Child Sexual Abuse Exam. ACEP Now. June 2010.
  • Riviello R. EPs Should Continue to Improve Forensics Skills. ACEP Now. November 2013.
  • Forensic Emergency Medicine: Practitioners Must Consider Roles as Investigators, Reporters. AHC Media, ED Legal Letter, 1 May 2002.

Webinars

Websites

Blog

National organizations

Conferences

Coursework to consider completing

 

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