Problems in Postmortem Pathology Training
Ali Rıza TÜMER1, Emirhan ESKİCİOĞLU1, Cenk SÖKMENSÜER2, Tuğçe FINDIKOĞLU1
1Department of Forensic Medicine, Hacettepe University Faculty of Medicine, ANKARA, TURKEY
2Department of Pathology, Hacettepe University Faculty of Medicine, ANKARA, TURKEY
Keywords: Forensic pathology, Forensic medicine, Medical residency
In Turkey, autopsy performers, namely forensic medicine practitioners, are neither pathologists nor have properly received pathology
training during residency in contrast to the Anglo-Saxon model of forensic medicine practices, since the current curriculum of forensic medicine
residency lacks adequate training in post-mortem histopathology. Likewise, pathologists lack a specific post-mortem pathology clerkship. In
this study, we intended to determine whether forensic physicians in Turkey find themselves competent in post-mortem histopathology or were
adequately trained during their residencies.
Material and Method: Turkish forensic medicine practitioners were administered an online questionnaire whereby self-evaluations of their
histopathology knowledge and their views on histopathology training during forensic medicine residency were assessed. The 151 physicians who
completed the questionnaire made up the study group.
Results: It was found out that the majority of Turkish forensic medicine practitioners (85.4%) did not find the histopathology training during
their residency adequate. Similarly, 85.4% of the participants indicated their incompetence in histopathological examination of post-mortem
tissue of any kind, and showed their willingness for further training in pathology. 66.9% strongly agreed that post-mortem histopathology
requires training that is distinct from surgical pathology. In case of providing post-mortem histopathology training within the scope of forensic
medicine residency, topics such as microscopic morphology of post-mortem changes, histological changes related to injuries, and estimation of
wound age are expected to be beneficial to 88.7% 83.4%, and 83.4% of the participants respectively.
Conclusion: The current curriculum should be revised in a way that the surgical pathology clerkship meets forensic physicians needs, so
that they can then refer more difficult, non-routine histopathological consultations to pathologists who are also well-trained in postmortem
histopathology. Consideration should also be given to establishing a subspecialty training - a masters or doctoral degree programs in forensic
Postmortem histopathology is a field of medical sciences
that examines tissues retrieved from a deceased individual
under a light microscope for various purposes 1
contrast to the Anglo-Saxon model of forensic medicine
practices, forensic physicians interest and competence in
the field of histopathology varies in the Middle East and
Continental European countries, where forensic medicine
practitioners are separate from physicians who perform
post-mortem histopathological examinations. There is
a similar situation in Turkey, as the forensic medicine
structure was adapted from Continental Europe.
Postmortem histopathology deals with the forensic
evaluation of a post-mortem tissue in any context, and the
significance of a particular finding as forensic evidence.
Post-mortem histopathology includes basic phenomena
such as post-mortem changes in cells and tissues, evidence
of vitality at the time a lesion occurred, the mechanism
of injuries, and the ruling out or confirmation of any
pathological changes in identifying the cause of death 2. Histopathology is a routine part of post-mortem
examination and can provide useful information for case
solution, not only in cases where the cause of death cannot
be determined by macroscopic findings, but even when the
cause of death is apparent to the naked eye at autopsy 3.
In post-mortem examinations around the world, generally
speaking, there are two types of forensic autopsy performers:
pathologists who are subspecialized in forensics
and physicians who undergo forensic medicine residency
training. In Turkey, autopsy performers are not pathologists
and pathologists do not regularly perform autopsy
(forensic or medical) and lack structured training of postmortem
In this study, we surveyed forensic physicians in Turkey to
determine whether they were trained in the field of postmortem
histopathology during their residency, whether
they had ever performed a histopathological examination
of a post-mortem specimen, if they have access to basic
histopathology equipment, and if any revision should be
applied to forensic medicine residency program so that a collaborative and goal-oriented training strategy with
pathologists is established.
As the study population, it was intended to include all
physicians actively practicing forensic medicine in Turkey.
The number is known to be around 800 according to the
data provided by the Association of Forensic Medicine
Specialists (ATUD). Invitations to participate were made
by sending out the online questionnaire via a platform
accessible to all Turkish forensic medicine practitioners.
Online notifiers were issued at two-week intervals for
4 times and the invites must have reached 427 forensic
medicine practitioners considering that the platform
has that quantity of members. Eventually a total of 151
physicians (response rate: 151/427, 35.4%) who completed
the questionnaire made up the study group.
The online survey method was chosen as the method of data
collection. In terms of structure, the questionnaire consists
of four sets of questions. The first set aims to determine
the academic titles of the participants, the institutions they
work in, and their access to a light microscope. The second
set of questions concerns the study groups self-evaluation
of their histopathological competency. Their views on the
formation of histopathology as well as the topics expected
to be beneficial in histopathology training during forensic
medicine residency training were asked with the third set
of questions, and finally, the fourth set determined their
preference of forensic histopathological practice.
This study was reviewed and approved by the Non-
Interventional Clinical Research Ethics Committee of
Hacettepe University (issue date 02/03/2021, number
presents the academic titles of the participants and
the institutions where they completed their residency.
Among all participants, residents composed more than
half (55.0%, n=83) while the rest were attending physicians
(27.8%, n=42) and professors (17.2%, n=26). In Turkey,
forensic medicine residency is available in three structurally
different institutions: training and research hospitals,
the Council of Forensic Medicine (under the Ministry of
Justice), and universities. Most of the participants (80.8%,
n=122) were currently residents or had completed their
residency at a university.
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|Table I: Participants academic titles and institutions where their residency took place.
When asked about the availability of a light microscope,
92 physicians (60.9%) stated that they do not have a light
microscope available at work while 42 (27.8%) stated that they can use a light microscope at will. The use of
microscope was stated to be subject to some permissions
for 17 (11.3%) of 151 participants.
The participants self-evaluations of the histopathology
training during their residency are presented in Table II.
The survey revealed the majority (85.4%, n=129) do not
find histopathology training during their residency to be
adequate. Similarly, 85.4% (n=129) of participants indicate
their incompetence in histopathological examination
of post-mortem tissue of any kind, with only a small
portion (2.0%, n=3) claiming competence in post-mortem
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|Table II: The participants self-evaluations of their histopathology training.
Using a five-point Likert-type scaling, the views of
participants on the formation of histopathology training
were determined and the data are shown in Table III.
66.9% (n=101) strongly agree to the proposal that postmortem
histopathology requires a distinct training from
conventional pathology, while 1.3% (n=2) strongly disagree
and 3.3% (n=5) are indecisive. Among 151 participants,
94 (62.3%) strongly and 42 (27.8%) moderately agree that
additional post-mortem histopathology training should
be available throughout forensic medicine residency.
61 subjects (40.4%) strongly and 56 (37.1%) moderately
agree that performing a certain number of histopathologic
examinations should be obligatory in order to complete
forensic medicine residency, while 12 (7.9%) slightly and
12 (7.9%) totally disagree. Among physicians enrolled
in this study, 63 of 151 (41.7%) strongly disapprove the
statement that there are adequate research and studies in
the field of post-mortem histopathology. While 49 subjects
(32.5%) remained undecided, 8 (5.3%) slightly approved. It
was revealed that no participant strongly agreed with that
Click Here to Zoom
|Table III: Views of participants on the formation of histopathology training.
In case of providing post-mortem histopathology training
within the scope of forensic medicine residency, topics
such as microscopic morphology of post-mortem changes,
histological changes related to injuries, estimation of
wound age, vitality markers of wound, and tissue handling
(sampling, transportation and preservation) during
autopsy are expected to be beneficial to 88.7% (n=134),
83.4% (n=126), 83.4% (n=126), 81.5% (n=123), and 79.5%
(n=120) of the participants respectively (Table IV).
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|Table IV: Topics expected to be beneficial in case of providing post-mortem histopathology training.
At the end of the questionnaire, two distinct practices of
whether post-mortem histopathological examination
should be carried out by the medical examiner (who is not
essentially a pathologist) who performs the autopsy or by a
different pathology specialist were presented. Roughly half
(50.3%, n=77) of the participants indicated professionals who perform autopsy and post-mortem histopathological
tissue examination should be one and the same, as in
the West (in the UK and the USA), while 49.7% (n=74)
supported the idea that the medical examiner performing
autopsy should consult someone else and especially a
forensic pathologist when needed, as in some European
countries like Germany, Greece, and Italy.
In addition to the external examination of the deceased
and autopsy, histopathological study is carried out
as an integral part of post-mortem investigations 4
Post-mortem histopathological examination aiming
to verify abnormal findings discovered at autopsy and
sometimes to guide medicolegal investigations 2,
has different practices in various forensic science schools.
This distinction is primarily apparent between physicians
who perform forensic autopsies and the ones carrying out
In the USA and the UK, post-mortem histopathological
specimens are evaluated by the same specialists who
perform autopsies if a microscopic assessment is required.
Professionals performing autopsy in the USA and the UK
specialize in pathology. Within a subspecialty program
called forensic pathology, those pathology specialists
are trained in various fields of forensic sciences such as
anthropology, toxicology, wound ballistics, and blood and
body fluid analysis, and consequently become forensic
pathology specialists 5,6. In other words, those physicians
become forensic medicine specialists after undergoing a
pathology specialization training.
In European countries such as Germany, Greece, and Italy,
tissue specimens obtained at autopsy are examined under
the light microscope and reported by distinct physicians
specialized in the field of histopathology.
It is seen that physicians performing autopsies begin their
forensic medicine residency directly after graduation from
the faculty of medicine and undergo histopathology training
throughout their post-graduate specialization training. This
clinical clerkship in histopathology is usually time-limited
and takes place in pathology laboratories. Being compulsory
for 6 months and elective for 6 more, those rotations could
be provided for a total of 12 months in Germany 7, whereas in France this clerkship is available as an elective
anatomic pathology training for 2 semesters of total 8
academic-term-long forensic medicine residency program
8. The medical literature lacks publications about the
competence of European forensic medicine practitioners
in post-mortem histopathological examination except
a few papers mentioning that in Germany, forensic
medicine is regarded as a distinct medical specialty called
Rechtsmedizin whilst histopathology is an integral
element of residency training, and to examine a total of
2,000 (two thousand) histological specimens is a must in
order to complete the specialization program 9.
Autopsies in Turkey are carried out by physicians, who
have completed a four-year residency program in forensic
medicine that does not include extensive training in
histopathology, and tissue specimens obtained during
autopsies are then referred to pathologists after being
appropriately collected for microscopic assessment.
Despite not being a member state of the European
Union, Turkish medical education authorities adapted
the European system and structured the forensic medical
residency training so that residents would experience
a two-month-long histopathology clerkship in surgical
pathology, whose goals are to earn competence in the
macroscopic sampling and the interpretation of pathology
reports as outlined in the Core Curriculum for Residency
in Forensic Medicine v2.4. (2018-2019) established by
Board of Specialization in Medicine (under the Ministry of
Health) 10. Hence it is deductible that actively performing the microscopic analysis of the tissue directly is not among
the competence goals of the curriculum.
We intend to draw attention to these two distinct practices
of post-mortem examinations by trying to find out whether
this long-standing tradition in Turkish forensic medicine
practices exists due to inadequacy of histopathology
training during the forensic medicine residency program,
Considering that earning a professor title takes at least
15 years in the profession and that 81.0% of the professors
declared inadequate histopathology training (Table II),
the forementioned lack of proper pathology training in
forensic medicine residency program must have existed
even at those times that they were residents, because apart
from personal interest, microscopic examination does
not fall within the everyday practice routine of a forensic
Pathologists deal mostly with biopsies and intraoperatively
resected tissues/organs during their training, though, at
their discretion, they may have a chance to work for a very
limited time in laboratories that examine post-mortem
tissues. Even when they are required to perform postmortem
examinations (which is also seldom), these are
mostly medical autopsies of fetus and newborns. Thus, the
only way a pathologist completing residency in Turkey
could undergo post-mortem histopathology training
is by working at a laboratory or a clinic where postmortem
investigations are constantly performed, although
pathology residents are obliged to perform autopsies in
order to complete their residencies. Besides, post-mortem
biopsy is another procedure that can be carried out if given
In addition, there is no clerkship defined in the Core
Curriculum for Residency in Surgical Pathology v2.4
(2019) for surgical pathology 11. In fact, apart from
cytopathology, there is no officially defined subspecialty of
surgical pathology in Turkey 12.
This state of inadequacy also hinders the forensic medicine
residents in surgical pathology clerkships from receiving
satisfying training on the examination of post-mortem
tissues as it would not be legitimate to expect a pathologist
lacking sufficient experience in post-mortem examination
to instruct or guide another physician on this issue.
From the perspective of forensic medicine physicians, it was
agreed by 142 of the total of 151 (94.0%) participants that
post-mortem histopathology training requires a different
training than conventional surgical pathology (Table III).
In order to acquire some competency in microscopic
examinations, 117 participants (77.5%) supported an obligation to perform a certain number of histopathological
examinations throughout forensic medicine residency as in
the German system.
As they demand forensics-oriented training, some specific
topics are expected to be advantageous if learnt (Table
VI): microscopic morphology of post-mortem changes
(88.7%), estimation of wound age (83.4%), histological
changes related to injury (81.5%), and histological changes
related to asphyxia (70.9%). Even though some pathologyspecific
topics like neuro-histopathology (39.0%) or
immunohistochemical methods (53.0%) are revealed to
be less demanded by forensic physicians, getting to know
cardiac histopathology appears to be beneficial to the
majority of forensic physicians (76.8%). The most likely
reason is that heart dissection takes place in each autopsy
Regardless of which system is adopted, the Anglo-Saxon
or the European one, post-mortem histopathological
investigations are executed by pathology specialists, while
autopsies could be performed by both pathologists and
non-pathologist forensic medicine physicians.
In spite of the fact that Turkish forensic medicine
practitioners are willing to acquire some microscopy skills,
lack of pathologists trained in forensic sciences constitutes
a barrier to provide adequate training. In Turkey, most of
the autopsies are executed in divisional branches of the
Council of Forensic Medicine. Therefore, the pathologists at
those clinics gain experience in post-mortem investigations
by examining tissue specimens obtained during autopsy
on a regular basis. However, in other institutions where
forensic autopsies do not take place, the pathologists would
not have the opportunity to examine or be acquainted
with post-mortem tissue specimens, and thus would lack
adequate knowledge to instruct the residents of forensic
medicine during their pathology clerkships.
Within the frame of the current forensic medicine
residency curriculum, it would be almost impossible to
gain adequate experience and knowledge in microscopic
examinations since a 2-month-long clerkship would not
be enough to get acquainted with a sufficient number of
specimens. Considering the practices around the world, at
least one year of pathology training specifically focused on
post-mortem microscopic morphology should be provided
for forensic medicine residents. Similarly, at least 3-monthlong
post-mortem histopathology clerkships should be
established for pathology residents in institutions where
forensic autopsy is a routine procedure.
Since the current practice of autopsies being performed
by forensic medicine physicians and histopathological
examinations being carried out by pathologists stays on
track, there is no need for a forensic medicine practitioner
to take over the role of pathologist. Nonetheless, in order
to meet international standards in forensic medicine
residency training, the authors feel that the current
curriculum should be revised in a way that the surgical
pathology clerkship meets forensic physicians needs and
that the competence goals include being able to identify
basic and most common pathological phenomena under
the light microscope. Forensic medicine physicians can
then refer more difficult, non-routine histopathological
consultations to pathologists who are also well-trained in
We hope this study will encourage both forensic medicine
and pathology physicians to review their residency
trainings, so that forensic medicine practitioners could be
provided with goal-oriented pathology clerkships rotations
to gain experience in basic histopathological examinations.
Consideration should also be given to establishing a
subspecialty training - a masters or doctoral degree
programs in forensic pathology - and made available
to forensic medicine, histopathology and anatomy
practitioners if the above mentioned suggestions to the
current curricula appear to be impractical at the moment.
Even further, how forensic medicine and pathology
specialists could collaborate to perform forensic autopsies
and how such settings could be ensured are other questions
CONFLICT OF INTEREST
The authors declare no conflict of interest.
This research did not receive any specific grant from
funding agencies in the public, commercial, or not-forprofit
Concept: ART, Design: ART, TF, Data collection or
processing: TF, Analysis or Interpretation: ART, EE, CS,
Literature search: EE, TF, Writing: ART, EE, TF, Approval:
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