TRASH-CAN: An Approach to Promote Planetary Health Education and Research for Health Care Trainees Open Access

Climate change is recognized by multiple international organizations as the number one threat to the health of humanity.^1,2  Paradoxically, health care systems themselves have a massive carbon footprint.^3,4  The current climate crisis demands that residents are educated about the environmental impact of health care and able to implement new ideas to reduce it. Planetary health is a “solutions-oriented, transdisciplinary field and social movement focused on analyzing and addressing the impacts of destabilized natural systems on human health and all life on Earth.”⁵  Currently, there are limited opportunities for education and engagement in planetary health work during Canadian medical residency, and the breadth of this subject can make starting new projects daunting.^6,7  The process of quality improvement (QI) used to systematically improve care can break this down and afford residents the opportunity to take ownership over specific elements of health care delivery, as well as contribute to mitigating the carbon footprint of our activities.

To address the existing regional and national gaps in planetary health engagement, Trainee-Led Research and Audit for Sustainability in Healthcare Canada (TRASH-CAN) is a new national resident-driven initiative that aims to reduce the environmental impact and carbon footprint of Canadian health care through the utilization of a QI “triple bottom line” approach while also upholding the highest standards of patient care. Our initiative was inspired by the Trainee-Led Research and Audit in Anaesthesia for Sustainable Healthcare (TRA2SH) organization that operates out of Australia and New Zealand.⁸  TRASH-CAN serves to educate residents and medical students, engage them meaningfully in planetary health work, and empower them to implement sustainable practices in health care. This brief report highlights our approach and TRASH-CAN’s early outcomes during its inaugural year of operation.

To launch the TRASH-CAN initiative, our initial steering committee (comprised of staff and residents from different disciplines with experience in planetary health) first established 3 pillars around which to focus our efforts. These pillars are:

1. Learning: We promote the appreciation and implementation of peer-reviewed literature on environmental sustainability in health care. Our goal is to develop a curriculum that will offer curated articles and videos that can serve as a foundation of knowledge for trainees.

2. Leadership: We empower TRASH-CAN trainees to assume leadership positions and share their expertise with institutions on the leading edge of similar efforts in Canada and internationally. It is our aim that trainees engaged with TRASH-CAN will continue on as sustainability champions as they enter independent clinical practice.

3. Delivery: We have set out with the goal of launching, leading, and supporting various QI projects that focus on meaningfully reducing waste in many areas of health care.

To scale and facilitate these pillars, our web-based platform⁹  allows us to connect residents and faculty to drive trainee-led action. This platform hosts intake forms for both trainees and mentoring staff physicians (provided as online supplementary data), which are summarized in the online supplementary data Table. After signing up, residents and staff mentors are paired together by the TRASH-CAN team on the basis of geographical proximity and area of expertise, to support trainees in the planning and execution of sustainable QI projects. The initial outcomes we measured were the number and type of trainee-led projects, the specialties of the project leaders, and the number of faculty members and trainees who signed up for mentorship pairing.

We officially launched TRASH-CAN on April 22, 2023. Our website is now fully functional with intake forms for both mentors and trainees (online supplementary data), a regularly updated list of ongoing projects, and a catalog of mentors who are currently available for matching.

For our Learning pillar, we have already initiated a project creating and curating educational material for internal medicine residents. For our Leadership pillar, we have partnered with organizations including the Australian trainee-led health care sustainability organization TRA2SH, as well as the Ontario Surgical Quality Improvement Network. We have also partnered with the Canadian organization CASCADES (Creating a Sustainable Canadian Health System in a Climate Crisis) to further support trainees in creating change in the perioperative environment, for example by applying the CASCADES perioperative scorecard and playbook.¹⁰  For our Delivery pillar, we have already initiated several trainee-led projects which are summarized in the Table.

Exactly 1 year after the launch of the initiative, we have had 15 faculty mentors sign up from institutions across Canada. TRASH-CAN’s web platform has had 16 trainees sign up to be paired with mentors so that they can begin their own journeys into sustainable QI.

In its first year of operation, our TRASH-CAN initiative has demonstrated its feasibility in recruiting faculty mentors and trainees and initiating various QI projects to decarbonize health care. We have had trainees and mentors sign up from institutions across Canada from a broad range of clinical specialities.

Currently, there is an important gap in Canadian medical training with regards to planetary health. Efforts to address similar gaps are underway in Australia and New Zealand through the TRA2SH initiative from which we drew inspiration. In Canada, at the level of undergraduate medical education, existing efforts include the Project Green Healthcare initiative and the Planetary Health Report Card.^7,11  TRASH-CAN complements these existing initiatives by using an approach specifically targeted toward postgraduate training.

Some of the limitations of the TRASH-CAN initiative are resource availability, outcome measurement, and engagement/participation. Not all institutions may have the necessary resources, such as funding, personnel, or technology, to implement and sustain additional QI projects, which could limit the scalability across different health care settings. Accurately measuring the environmental impact and cost savings of projects can be challenging. There may be limitations in data availability, consistency, and accuracy, which could affect the reliability of these measurements. Finally, sustaining high levels of engagement among faculty, trainees, and other stakeholders can be difficult: busy schedules and competing priorities may reduce the time and effort participants can dedicate.

Looking ahead, our goal is to iteratively improve TRASH-CAN’s work by implementing measurements of the following outcomes related to our initial 3 pillars:

1. Learning: We continue to measure the growing number of mentors and trainees who choose to support sustainable Canadian health care through involvement in TRASH-CAN. We intend to survey our membership’s baseline understanding of sustainable practice in perioperative and inpatient care.

2. Leadership: We will monitor the presentation of TRASH-CAN projects by trainees at regional, national, and international conferences, and track institutions and departments across the country that are involved in our collaborations.

3. Delivery: We will quantify projects completed over the initial 12- and 24-month periods of TRASH-CAN’s operation. We will create a database of sustainability initiatives that other centers can use as a model for best practice, safe implementation, and high level of evidence.

It is our vision that engaging trainees in evaluating and enhancing the perioperative environment will contribute to the training of sustainability leaders in our profession, while also continuously improving the care that we can offer current and future patients. For TRASH-CAN, we hope that collaborations, capacity building, and leadership based on ongoing resident and medical student involvement will allow this organization to continue to grow. Having faculty involved as part of the leadership team from its inception will also give another perspective to ensure that the program itself remains sustainable.

Since launching in Ontario in 2023, TRASH-CAN has recruited faculty mentors, residents, and medical students from a range of medical specialities to plan and institute several quality improvement sustainability initiatives.

The online supplementary data contains the trainee and mentor intake forms.

Funding: The authors report no external funding source for this study.

Conflict of interest: The authors declare they have no competing interests.

The work was previously presented at the International Conference on Residency Education, October 19-21, 2023, Halifax, Nova Scotia, Canada; the International Summit on Leadership Education for Physicians, October 18, 2023, Halifax, Nova Scotia, Canada; the Canadian Surgery Forum, September 20-23, 2023, Vancouver, British Columbia, Canada; the American College of Surgeons Quality and Safety Conference, July 10-13, 2023, Minneapolis, Minnesota, USA; and Collins Day—University of Ottawa Department of Surgery Research Day, May 19, 2023, Ottawa, Ontario, Canada.