Early in her career, Susan Ely helped put a serial killer behind bars.
It was the late 1990s, and she was working as a fellow at the Office of Chief Medical Examiner (OCME) of the City of New York. Ely had to perform hundreds of autopsies during her training year, and for one particular investigation, she performed an autopsy on a young murder victim.
"It was a terrible situation," said Ely, who recently joined the Yale faculty as an associate professor of pathology and director of the autopsy service at Yale School of Medicine (YSM). "There were many issues that were not at all initially clear."
But as she worked on the case, one thing did become clear: The individual was likely the victim of a serial killer. Through their work across different agencies and boroughs, Ely and her colleagues noticed similarities between the woman's death and other cases involving strangulation. There was a clear pattern, as well as DNA evidence, that ultimately led to a conviction.
"You come away feeling like you were part of something that was hugely important to get right, something that affected so many, but particularly the victims' families," she said.
A forensic pathologist by training, Ely spent 26 years as a medical examiner with New York City's OCME, the largest medical examiner's office in the country, and more recently was with the Connecticut Office of the Chief Medical Examiner.
Though the terms are often used interchangeably, there are some differences between forensic pathologists and medical examiners. A forensic pathologist is a specialized medical doctor who investigates unexpected, unnatural, suspicious, or violent deaths either publicly or in private practice. A medical examiner is a public official, typically a forensic pathologist, who conducts similar investigations that fall by statute within a given jurisdiction, for example, New York City.
In their roles, medical examiners determine the cause and manner of certain deaths. But their work extends far beyond the autopsy room and includes coordination in criminal investigations, public health matters, and legal proceedings. For Ely, that meant everything from reviewing police reports and city and state infant and maternal mortality data to testifying in courts of law as an expert witness and counseling grieving families.
Over the course of her career, Ely has been part of few serial killer cases. More commonly, she has investigated deaths resulting from motor vehicle accidents, mass fatality events, suicides, drug overdoses, and even public health crises like the COVID-19 pandemic. Early in her career, she and her colleagues at NYC OCME even handled the death investigations resulting from the Sept. 11, 2001, attacks.
In a conversation with Yale News, Ely discussed the depictions of medical examiners in pop culture, the complexity of navigating traumatic cases, and the importance of educating the next generation of forensic pathologists.
How did you get into forensic pathology?
Susan Ely: I would say a fair amount of serendipity led me here. Forensic pathology was absolutely not on my radar when I was coming up through medical school. After medical school, I had many interests; in fact, I initially started out in psychiatry. I then did a year of internal medicine before I discovered pathology. Once in pathology, residents are required to rotate through a medical examiner's office to be eligible for their boards. So, I did my requisite month in NYC, and that's when a whole world opened up to me.
I was drawn to the people, including those who became my mentors, but I was also drawn to the specialty itself. When I look back on it now, it makes sense. It's where my medical interests - psychiatry, internal medicine, public health, and pathology - converged.
As a medical examiner, you've had to work on many difficult, even traumatic, cases. How did you take care of yourself?
Ely: Much like any doctor, you enter this silo of the diagnostic space where you have some clinical distance by necessity. You're really tuned in to left brain activity. Without that, you really can't do your job as effectively. Of course, you still have human emotion and compassion, but you're also very focused on the task at hand. Over the years, the times that I've been most affected have been outside of the autopsy room, in my telephone conversations with families when suddenly you get a glimpse of the patient's life, of who they were and what they left behind, when you've gone to a death scene and seen where this person lived or photographs of them on a dresser. That's when you might have to kind of choke back a little bit.
There are so many TV shows about forensic pathology, from "CSI" and "Law and Order" to "Criminal Minds" and "Bones." How does pop culture shape our perceptions of medical examiners? Is the "CSI effect" real?
Ely: Hopefully, people don't picture some guy eating a ham sandwich in the autopsy room anymore. But the "CSI effect" is a legitimate thing that's cited in forensic textbooks. You do have to manage expectations, especially in the courtroom. The role of any forensic pathologist is to be a neutral arbiter of the facts, to not have a dog in the fight. The forensic pathologist is not coming in to stake a claim. They're there to educate the jury and to make sure that they are in possession of enough accurate medical facts and concepts so that by the end of the testimony, they can make a very important, evidence-based decision, particularly important in criminal cases, but also in many civil cases.
People may think that we can offer a precise time off death, that, for example, an individual died at 9:02 p.m. Absent a witness, though, there's just no medical science that allows us to estimate a time of death with that kind of precision. Another thing that television often gets wrong is an underestimation of the nuance of many investigations and the amount of time and work professionals who have been trained for many years are putting into them. Some of them are incredibly complex and we're often answering questions that extend far beyond just the cause of death. We're looking at what initiated the lethal sequence of events and the variables that stand between that first event and the fatal outcome. We consider the evidence for all the biochemical and pathophysiologic iterations of the dying process, known as the mechanisms of death. That means figuring out how that cause ended in death, and what it may have looked like in the process.
Forensic pathologists also have to communicate much more than one might imagine. They have to testify in court, communicate findings to nearly every type of medical specialist, and have often fraught discussions with bereaved families, detectives, public health officials, and countless lawyers. But that's always been attractive to me. I enjoy the challenge and emphasis on clear and accurate communication.
Why are these shows so popular? Why are so many of us fascinated by the field of forensic pathology?
Ely: Many people like mystery novels - it's a similar kind of riddle. It's something that needs to be unraveled. Because I saw so many outliers of the human condition as a routine part of my job, some of the things that may not seem extraordinary to me would be extraordinary for most people to encounter. Many of these things are inherently interesting to many people. Plus, television has done a good job of placing a glamorous sheen on the work.
Why did you decide to come to Yale?
Ely: By the time I left New York City, I had been doing medical examiner work for 26 years. I loved all of it, but especially my time as the program director for our fellowship program. There's little I have enjoyed more in my career than medical education and teaching fellows, residents, and students. I truly love it and that was a central factor in my desire to come to Yale. The autopsy service and pathology department here are top notch, and that was the case long before I came. Where applicable, though, I hope to bring some forensic practice approaches to the hospital autopsy service.
I do think that autopsy pathology in general suffers from a PR problem. I'd like to help mitigate that and serve as a sort of ambassador to disseminate more accurate information about general and autopsy pathology practices to medical students and even undergraduates. I, like many others in forensic pathology, have a mission to shine a light on autopsy education and the critical multidisciplinary fields that stem from it.
