After eight years of searching, why can’t Rhode Island hire a permanent chief medical examiner?

Dr. Lance Truong fell in love with Rhode Island after the pathology program at Brown University brought him here four years ago. Back then, he had just graduated from medical school in Las Vegas. Now he is chief resident of pathology at Rhode Island Hospital.

But in July, Truong, 33, along with his wife and 9-month-old daughter, are leaving Rhode Island so he can train in pediatric pathology at Boston Children’s Hospital. Then he plans to pursue a forensic pathology fellowship, most likely in a large metropolitan area like Chicago, Las Vegas, or Oklahoma City.

Why can’t Rhode Island find a state health director?

Part of the reason for Truong’s departure can’t be helped: Rhode Island does not offer a forensic pathology fellowship. But he is unlikely to return because opportunities elsewhere offer more competitive salaries and better cost of living conditions, important considerations for doctors who have accumulated mounds of debt during their training. And Truong is not alone — he said his fellow pathology residents are also looking elsewhere.

“We love this place. We love the community. We’re dedicated to this population, [but] the math doesn’t work out,” Truong said.

Forensic pathologists are in high demand nationwide, but are particularly needed in Rhode Island. But the same concerns that drive early career pathologists like Truong away from Rhode Island may also explain why the state can’t lure experienced ones to take jobs here. 

It has been more than eight years since Rhode Island had a chief medical examiner. The state’s former head pathologist Christina Stanley resigned in August 2015 after being placed on administrative leave. The office’s struggle with backlogs and staffing issues led to the downgrading of its national accreditation. Since then, the office has been staffed, in part, by an acting chief medical examiner and contractors. The Health Department also has struggled to find a permanent director.

Until recently, Rhode Island offered some of the lowest-paying positions for chief and assistant medical examiners in New England. In Massachusetts, the chief medical examiner office is the highest paid employee of the state’s executive branch, making nearly $422,000, an eyebrow-raising salary that has drawn scrutiny. In Connecticut, the chief medical examiner made more than $460,000 in 2023. Vermont’s earns nearly $300,000, and New Hampshire’s earned about $262,000 in 2022. Maine is offering $285,000-$310,000 to hire a new one. 

During Stanley’s tenure, Rhode Island’s chief medical examiner earned less than $240,000, but the position has received pay bumps over the years to make it more appealing to potential candidates. In the fiscal 2024 state budget, a pay increase was approved to raise it to $375,000, up from about $280,000 in 2023. 

But assistant medical examiners, an entry level position for fellows graduating from a forensic pathology program, earn significantly less — between $207,595 to $226,146. — despite also recently receiving a pay raise. In Connecticut’s office of the medical examiner, physicians earn between $326,420 to $391,624. In Massachusetts, the base pay for assistant medical examiners ranges widely, from $133,821 to $285,329.

“You don’t feel like a winner when you sign these contracts here in this area,” said Truong. 

The pay raises may help make Rhode Island a more competitive employer for medical examiners, but the Health Department still faces the challenge of a national shortage of trained pathologists.

“It’s a specialty which is not very common, meaning not too many people have qualified. As a result, luring them to come and work for the State of Rhode Island from an already small pool has been our challenge,” said Seema Dixit, a deputy director at Rhode Island’s Department of Health.

The profession requires extensive training: four years of medical school, another three to four years of training in anatomical pathology and a one-year fellowship in forensic pathology. Only 47 programs in the country — usually hosted by an office of medical examiner — offer the fellowship, but none are available in Rhode Island. Aspiring medical examiners have to leave the state to receive their training.

The field faces both recruitment and retention problems. Pathology is among the least competitive medical specialties. Less than 1% of medical students choose to pursue it. Even fewer become forensic pathologists, the credential required to work as a medical examiner. In 2023, only 45 pathologists got into forensic pathology fellowships in the U.S.

There are currently about 500 forensic pathologists in the U.S., less than half of the estimated 1,280 needed to meet the needs of the U.S. population. And the total number of practicing pathologists has been shrinking over the past decade and is estimated to continue contracting in the coming years.

Appeal of contract work

Bereft of permanent pathologists on staff, health departments often turn to contractors. This can make their budgets balloon. Rhode Island has five contract part-time assistant medical examiners. In fiscal year 2021, the office spent about $245,000 in contract services; for fiscal year 2023 the department set aside approximately $1.33 million for contract services. In the first eight months of fiscal 2024, the state has spent $779,900.

Pathologists working in the public sector earn one-half to one-third of what those who work in hospitals or private practice earn. Contracting may be more appealing than taking a full-time position with the office of medical examiner. 

“Forensic pathologists prefer contracting so they can pick and choose their assignments and also get compensated probably more than being employed at one place,” Dixit said.

In 2022, the Department of Health brought on Florida-based MASC Medical Recruitment Firm to lead a national search for its chief medical examiner. But the firm was unable to find or refer any applicants for the position and the state paid no fees based on its contract with the firm: The fee structure was based on MASC being able to find a candidate that was selected, approved, and hired. 

The office is now working to identify another recruiting agency that specializes in physician searches. “We are seeking an agency that has a robust nationwide recruiting structure and has documented successes with recruiting medical examiners,” health department spokeswoman Annemarie Beardsworth said via email.

“We are doing our best with our existing consultants to ensure that the right quality of work is still being delivered. So is it easy? No. Is it cost effective? No. But the work quality continues, so hopefully we get somebody,” Dixit said.

The National Association of Medical Examiners has suggested incentives such as student loan repayment programs and better salaries. Recruiting pathologists trained overseas is also an option.

Truong said despite the negative headlines about the shortage of forensic pathologists in the country there is a cultural shift happening. In recent years, he has noticed more candidates for Brown University’s pathology residency interested in pursuing forensic pathology and working in the justice system. He reckons the pay increases are making a difference and that popular TV shows such as “CSI” have helped the public image of forensic pathology. In the wake of protests over the death of George Floyd, a Black man killed by a white police officer in Minneapolis, more doctors in training have felt called to join the justice system.

“I think there’s a lot of people with strong moral compasses coming and saying, ‘I’m going to be that change,’” Truong said.

Editor’s note: This story has been updated to include details on the hiring of a medical recruiting firm.

Correction: An earlier version of the story gave incorrect dollar amounts for how much the Rhode Island Department of Health spent on contract services for the Office of Medical Examiner in fiscal 2021 and 2024.