By Anne Blythe
As North Carolina’s chief medical examiner, Michelle Aurelius says she has trouble sleeping at night.
It’s not just because of the nature of her work — seeing that violent, suspicious and overdose-related deaths are adequately investigated from a medical perspective.
What troubles her is that medical examiner system cases in North Carolina have increased by almost 25 percent in just four fiscal years. In her office alone, which deals with some of the more complex cases, the autopsy workload has gone up by 49.9 percent since 2019.
Her workforce has not increased in years. Instead, it has shrunk over time as some pathologists retire and others burn out and leave.
Recruiting has its own obstacles and hurdles. Some pathologists just fresh out of medical fellowships head for other states that offer starting salaries tens of thousands of dollars higher than the $180,000 per year that North Carolina offers. Aurelius said she saw a flier recently for a $300,000 starting salary.
Because of the shortage in North Carolina, autopsy reports are not being completed as quickly as Aurelius would like. That leaves grieving families, law enforcement agencies and others awaiting answers. It can also mean a longer-than-expected wait for a death certificate, making it difficult for families trying to arrange funerals or meet insurance demands.
All this troubles Aurelius. Those in her morgue and labs are not simply victims of gun violence, homicide, drug overdoses or sudden unexplained death.
“Every single one, every single patient I have means something to me,” Aurelius said during a phone interview with NC Health News. “They are somebody’s loved one.”
Too few new forensic pathologists
Lawmakers on the Joint Legislative Oversight Committee on Health and Human Services were briefed Tuesday about the mounting workload and the workforce shortages plaguing all of the Department of Health and Human Services.
ClarLynda Williams-DeVane, a deputy secretary in the DHHS Division of Public Health, told lawmakers that North Carolina forensic pathologists in the medical examiner’s office have a workload nearly double the national standard.
A forensic pathologist, according to the national standard, should do about 250 autopsies per year, or no more than 326 at maximum peak caseload, Williams-DeVane said. At the office of the chief medical examiner each forensic pathologist, on average, does 557 autopsies per year, Williams-DeVane added.
This issue is not new to lawmakers. In 2014, Deborah Radisch, chief medical examiner at the time, spoke about trouble on the horizon.
The fix, as Aurelius sees it, needs to be a multi-pronged strategy.
The state could use more forensic pathologists in regional offices that used to take more cases, but the state reimbursement for those autopsies – that can cost nearly $5,800 – is only $2,800. That’s the rate set in statute by lawmakers in 2015, and it hasn’t increased since.
Currently, about 40 new forensic pathologists are coming out of medical fellowships and onto the job market in North Carolina each year, according to Williams-DeVane. The state has about 500 practicing board-certified forensic pathologists in a given year, but could use more than twice that number to help with the increasing workload.
In addition to the supply-side problems, the state’s hiring process and regulations for how they can reward employees are rigid. Once they are hired, supervisors have few options to reward loyal workers.
Because of workforce shortages across the board at DHHS during the pandemic, state of emergency orders allowed health care systems to use contract workers.
Not only do those workers demand a higher pay rate than state-salaried workers get, the state was able to offer signing bonuses to new workers.
There was no mechanism, though, for offering retention bonuses to state workers who had been loyal employees for years and stayed around to weather it out during the pandemic.
Seeking bureaucratic flexibility
Kody Kinsley, DHHS secretary, told lawmakers at the Tuesday meeting that in July the across-the-board job vacancy rate was 23.2 percent, nearly double the 12.7 percent vacancies in the department in March 2020.
The rates are even higher when you break it down for state-operated facilities and job categories. Most of those care facilities serve people with psychiatric issues, such as Central Regional Hospital and the state’s network of long-term care facilities for people with severe developmental disabilities.
The overall DHHS vacancy rate for registered nurses and social workers is 44 percent.
Pam Kuhno is the director of the Murdoch Developmental Center, one of those state-run facilities in Butner for people with intellectual and developmental disabilities.
In a telephone interview on Tuesday, she talked about the staffing difficulties at the center that she leads. Thirty-four percent of the registered and licensed nursing posts are vacant.
The state pays $6,000 to $10,000 per year less for such jobs than nurses can demand in the Triangle, a region with many health care facilities.
“The staff who are here are putting the needs of the people who live here above themselves and their families,” Kuhno said.
They often work overtime, though she limits the number of hours they can work consecutively. She worries now about what might happen around the holidays, when the hours have to be covered and the residents have to be cared for but she can’t grant time off for workers who are giving their all.
All these workforce issues mean that 2,341 fewer patients received care at state-run facilities in 2022 than in 2019.
Sen. Jim Perry, a Republican from Lenoir on the joint legislative committee as well as a chair of the Senate Health Care Committee, said on Tuesday that he’s open to changes that could provide DHHS flexibility in hiring and retention of its workforce.
“We’re in the most unique situation we’ve ever faced in the history of our state,” Perry said. “I don’t believe health care wages are going to go down in January of next year or the following January. So I do see, in my opinion, that you would benefit from some temporary flexibility still to move things around, to invest in our abilities. Just like wages aren’t going to go down, we’re also not going to create 20,000 new health care workers in the next day.”
Emery Milliken, deputy director of the DHHS Division of Health Service Regulation, calls the worker shortages “a staffing crisis.”
“I’m just going to call it what it is,” Milliken said Tuesday during a phone interview with NC Health News.
Her division has a sweeping range of responsibilities. It’s involved with the licensure of acute care services, home care and mental health care. The division provides regulatory oversight, receives and investigates complaints about health care personnel, and inspects facilities. It reviews architectural and engineering plans of health care and jail construction projects and more.
There are so many vacancies in her division that inspections and investigations are not occurring as frequently or as quickly as they should. Construction projects are being delayed, adding unnecessary costs, and workforce turnover in some of the positions is like a revolving door.
Milliken said she understood that a staffing problem at DHHS might not seem like a big deal to many residents in the state.
“The public wants to know, ‘but how does this affect us?’” Milliken said.
What she would like them to understand is that it’s a safety issue. It not only has an impact on anyone being treated in those health care facilities, it also could erode the overall ability of the department to tend to the public health of the state.
Sen. Donny Lambeth, a Winston-Salem Republican, put something on Kinsley’s to-do list at the Tuesday meeting that takes into account the workforce shortage woes. He asked for an action plan.
Kinsley agreed to take on that task.