Forensic Emergency Medicine Niche
Author
Sriram Venkatesan, FAWM
Medical Student
Sri Ramachandra Medical College, India
Vice Chair, EMRA Prehospital & Disaster Medicine Committee
EMRA Rep to the ACEP Tactical & Law Enforcement Medicine Section
Faculty Editor
Keesandra K. Agenor, MD, MS
Clinical Forensic Medicine (CFM) Fellowship Director
Department of Emergency Medicine
NYC Health + Hospitals | Kings County
Special thanks to our 2nd edition writing team
Spencer Lord, MD
Kyle Ackerman, MSII
INTRODUCTION
Description of the specialty
Emergency physicians are in the position to address the needs of the most vulnerable patients seeking care: trauma patients. Victims of trauma — including gunshots, stab wounds, motor vehicle crashes, and sexual assault — pass through the ED daily. Some rush in as notifications at our Level 1 and 2 trauma centers, and others wait for us silently behind a closed curtain or door.
Each of these patients have various levels of forensic needs, whether their chief complaint is forensically relevant or their needs were identified during the visit. Emergency physicians are in the ideal position to identify victims of intimate partner violence, elder mistreatment, child abuse, and human trafficking. In all of these cases, emergency physicians may be required to collect and preserve evidence, and provide detailed documentation, court testimony, and referrals to appropriate agencies. Thus, it is important for emergency 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
The number of patients who are victims of trauma and abuse and seek care in EDs has spiked. Emergency physicians are in a unique position to identify, evaluate, and treat these patients.
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, and ACEP’s Model of Emergency Medicine now requires proficiency in sexual assault training. However, very few residencies include clinical forensic medicine in their training curricula. Fellowships within this field are slowly developing, with the only active clinical forensic medicine fellowship currently housed in New York City at NYC Health + Hospitals Kings County (affiliated with SUNY Downstate EM Residency Program). There are also forensic preceptorships available; 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 forensic education and their 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?
Are you interested in forensic medical evaluations, 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? Do you have an interest in public health and working with local community leaders to create policies? Do you want to make a change in the community that you serve? 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:
- Medical director of a sexual assault response center
- Director of a child advocacy center (CAC)
- Director of forensics within departments of emergency medicine
- Researcher in forensics-related topics
- Forensics educator of residents, nurses, and other providers
- Forensics expert for criminal cases
- Forensics consultant for investigative media
- Medical advisor for local law enforcement and public health agencies
- Local and national speaking engagements
Splitting time between departments
Most clinicians interested in clinical forensic medicine will develop protocols, services, and/or programs 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 (e.g., police surgeon, medical expert witness) and then will split time between departments. Others may consider working in an ED at a sexual-assault-designated hospital and a CAC, sexual assault response center, or family justice 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 forensics involvement.
Academic vs. community positions
Those interested in teaching and/or research often gravitate toward 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 subspecialty.
IN-DEPTH SPECIALTY INFORMATION
Number of programs
The NYC Health + Hospitals/Kings County’s Clinical Forensic Medicine Fellowship is currently the only fellowship offered for this subspecialty. It is a one-year training program that teaches clinicians to identify and care for victims of violence and trauma, prevent the destruction of potential evidence, assist in legal proceedings, and recognize and document patterns of violence and abusive behavior. The program incorporates evidence collection, crime scene exposure, analyzing witness testimonials, and Sexual Assault Response Team (SART) practices. Contact the program directly for more information.
There are academic emergency medicine programs that house forensic departments. Currently, the training and track are more of an area of interest within emergency medicine. Therefore, it is important to contact program directors to discuss the scope of their program’s forensics training and department resources.
Preparing for a Career in Forensics
Research requirements
There is no research requirement to become involved in this field. However, clinical forensic medicine is a young field, so research opportunities abound, and it can illustrate your interest in this area.
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 forensics examiner teams.
Suggestions on how to excel during these elective rotations
Demonstrate your dedication, interest, and knowledge base. Read every day about relevant topics. Once the interest is there, it is difficult to escape it — forensics is everywhere (e.g., social media, news, academic articles). 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 (e.g., child abuse, elder abuse, sexual assault), then we highly encourage you to seek away elective opportunities. We encourage you to seek out programs that have forensics departments within their department (such as the NYC Health + Hospitals/Kings County’s Hospital, Drexel University College of Medicine, University Medical Center New Orleans, Baylor Scott & White Health, University of Kentucky, and University of Florida Gainesville) or EDs that are the designated center for assault/abuse and other forensic 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 interest even more within forensics (e.g., child abuse, elder abuse, intimate partner violence). Seek training through conferences, workshops, and online training modules to better educate yourself, and then subsequently educate others about the clinical application of forensics. Online training modules on multiple forensics topics are available through ACEP’s online continuing medical education repository. Learn the administrative skills that are needed to design and manage a forensics 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. Reach out to your institution’s risk management team for additional information. 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 can write up case studies on interesting cases you encounter in the ED. 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
- Walls R, Hockberger R, Gausche-Hill M, Erickson T, Wilcox S. Rosen's Emergency Medicine: Concepts and Clinical Practice. Elsevier Health Sciences; 2023.
- Olshaker JS, Jackson CM, Smock WS. Forensic Emergency Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.
- Payne-James J, Jones RM. Simpson's Forensic Medicine. 14th ed. Boca Raton, FL: CRC Press; 2020.
- Riviello R. Manual of Forensic Emergency Medicine: A Guide for Clinicians. Sudbury, MA: Jones and Bartlett Publishers; 2009.
- Spitz W, Diaz, F. Spitz and Fisher's MEDICOLEGAL INVESTIGATION OF DEATH: Guidelines for the Application of Pathology to Crime Investigation. 5th ed. Springfield, IL: Charles C Thomas Pub Ltd; 2020.
- American Academy of Pediatrics. Visual Diagnosis of Child Abuse, 4th edition (Online Resource). https://shop.aap.org/visual-diagnosis-of-child-abuse-4th-edition/
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 or get certified as a SAFE.
- Develop leadership and administrative skills to run the forensic medicine section of an emergency department.
- Develop effective educational skills to teach others about forensic medicine.
- Collaborate with residents from other specialities on quality improvement projects that can better serve trauma patients with forensic needs.
- Expand your knowledge about the legal system, and learn about court testimony.
- Foster a relationship with your local law enforcement or governmental agency.
- Understand the protocols to appropriately identify and assist potential human trafficking victims.
- Recognize the specific detail and documentation that is necessary for the admissibility of chart entries in legal proceedings.
- Support your local family justice center in providing assistance to victims and survivors of domestic and gender-based violence.
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 opportunities 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 with a background in 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
- Global Journal of Nursing & Forensic Studies
- Journal of Forensic Medicine
- Journal of Forensic and Legal Medicine
- Journal of Forensic Sciences
- Journal of Forensic Toxicology and Pharmacology
- Medical Toxicology and Clinical Forensic Medicine Journal
- The American Journal of Forensic Medicine and Pathology
Journal articles
- Armstrong M, Strack GB. Recognition and Documentation of Strangulation Crimes: A Review. JAMA Otolaryngol Head Neck Surg. 2016;142(9):891–897.
- Finn R. Tips for Conducting a Child Sexual Abuse Exam. ACEP Now. June 2010.
- Forensic Emergency Medicine: Practitioners Must Consider Roles as Investigators, Reporters. AHC Media, ED Legal Letter, 1 May 2002.
- Green W. Medical Evidence in Non-Fatal Strangulation Cases. The Investigation and Prosecution of Strangulation Cases. Training Institute on Strangulation Prevention and the California District Attorneys Association. 2013.
- Riviello R. EPs Should Continue to Improve Forensics Skills. ACEP Now. November 2013.
- Ryan M. Clinical Forensic Medicine. Ann Emerg Med. 2000;36(3):271-273.
Webinars
The Faculty of Forensic and Legal Medicine of the Royal College of Physicians
Websites
California Clinical Forensic Medicine Training Center
Health, Education, Advocacy, LinkageMassachusetts General Hospital: Division of Global Health and Human Rights
National Sexual Violence Resource Center
New York City Alliance Against Sexual Assault
Blog
http://clinicalgate.com/forensic-emergency-medicine/
National organizations
ACEP Forensic Medicine Section
American Academy of Forensic Sciences
Conferences
American Academy of Forensic Sciences Annual Scientific Assembly
Annual International Conference on Traffic and Transport Psychology
Hidden Homicides: The Challenges of Staged Crime Scenes (HOPE Alliance)
Strangulation Prevention (HOPE Alliance)
International Symposium on Child Abuse
International Conference by End Violence Against Women International
Coursework to consider completing
Comprehensive Forensic Medical Examiner Training (California Forensic Medical Institute)
Medical Training Academy for Child Physical and Sexual Abuse (a self-paced online course)
Master of Science in Forensic Science (Drexel University)
