Teaching Climate and Health in Preventive Medicine Residency Programs: A Survey of Program Directors

Climate change and environmental health are an urgent focus for public health professionals and physicians. Climate effects on health are direct (eg, extreme heat) and indirect (eg, vector range extensions). Increasing numbers of people are presenting for care with climate-related problems: extreme heat, injury from flooding and wind, vector-borne illness, respiratory distress from airborne particulates, and mental health issues related to real and expected illness.^1-7 

Training in climate and health for medical professionals is essential.^8-10  Medical schools in the United States and elsewhere are implementing medical student climate issue curricula,^11-15  but among US residency programs as of early 2024, only the American Academy of Pediatrics has published guidance for including climate health issues.^16-18 

Three medical fields within preventive medicine, public health and preventive medicine (PHPM), occupational and environmental medicine (OEM), and aerospace medicine (AM), train residents in both individual preventive care and population-based prevention.¹⁹  Many physicians in these specialties work in health departments and federal Department of Health and Human Services programs. Because climate change influences all these areas, preventive medicine professionals can contribute to the mitigation of and response to climate-related health problems at the individual, local, institutional, and nationwide levels.

This study examined the current prevalence of climate-related training in US preventive medicine residency programs.

A 9-question confidential survey was developed by the authors with guidance from a climate and health education expert. The list of topics included in the survey was not intended to be comprehensive but to include examples from the spectrum of climate and health issues. Question types included 3 open-ended, 3 yes/no/maybe, and 3 multiple-choice, covering climate-related curricula and interest in developing a common preventive medicine residency curriculum. Prior to launch, the survey was sent to 6 program directors (PDs) for comments to assess content validity. The survey was distributed to PHPM and OEM programs in January 2024, followed by 4 reminders. Individual emails were sent in March 2024 to the PDs of the 6 AM programs. The survey instrument is included as online supplementary data.

The American Colleges of Preventive Medicine and Occupational and Environmental Medicine supported the effort. Faculty of Rutgers University residency programs in PHPM and OEM developed and administered the survey.

Survey data were exported from SurveyMonkey (SurveyMonkey Inc) and were cleaned and analyzed using the JMP Pro 17.0 statistical package (JMP Statistical Discovery LLC). Summary statistics for continuous data and proportions (prevalence estimates) are presented with 95% confidence intervals. Bivariate analyses for nominal data used Fisher’s Exact, Kruskal-Wallis, and Wilcoxon pairwise comparison tests. Significance tests were conducted at the alpha .05 level.

The study was deemed as nonhuman subjects research by the Rutgers University Institutional Review Board.

The response rate was 49.3% (35 of 71 programs): PHPM 50.0% (21 of 42), OEM 52.2% (12 of 23), and AM 33.3% (2 of 6). Responding programs varied in size. AM programs reported a median of 14.5 residents, and PHPM and OEM programs reported medians of 5.2 and 5.5, respectively. One OEM PD did not provide information regarding climate health training, so the total sample was reduced to 34.

Two of the 34 responding programs (5.9%) reported having a formal curriculum for climate and health: one OEM and one AM. However, many programs answered “yes” to specific questions on residency training inclusion of health issues related to climate change (Table 1). There was no significant difference by program type.

Table 2 provides the number and percentage of respondents indicating specific climate and health topics included in current residency training. Over 50% reported covering climate-related vector-borne illnesses, public health issues related to fire, smoke, and heat, clinical management of heat- or cold-related overexposures, food security, and waterborne disease. Significant differences, comparing the 3 groups globally, were identified by program type for climate change trends/interpretation of climate change terms; public health issues related to flooding, wind/tornadoes, fire and smoke, and extreme cold; clinical management of heat- or cold-related overexposures; waterborne disease and water scarcity; and community resilience/adaptation strategies.

Only 2 of 34 (5.9%) of programs reported that they did not cover any of the topics included in the survey. There were notable differences by program type, with PHPM reporting significantly fewer topics than OEM programs, such as for “climate change trends and interpretation of climate change terms,” “clinical management of heat or cold-related overexposures,” “waterborne diseases,” and “community resilience and adaptation strategies” (Table 2). Free text options did not elicit additional information on topics or teaching methods.

The most frequent teaching method was didactic lectures, followed by rotations with local or state health departments, resident research projects, and tabletop exercises. Only 3 programs reported teaching advocacy work (eg, letter writing, visits to legislators).

Twenty-three of 34 (67.6%) PDs indicated a willingness to participate in an American College of Preventive Medicine–led team to develop a climate and health curriculum for preventive medicine residents (14 PHPM, 8 OEM, and 1 AM program).

This survey of US preventive medicine residency programs (PHPM, OEM, and AM) found that the vast majority included some climate and heath topics, but a formal curriculum was rare, despite PD interest in developing a common, standard curriculum.

The differences in content covered within the 3 types of preventive medicine residency programs, particularly PHPM and OEM, may be due to OEM being more advanced in integrating climate health into curricula than PHPM. OEM programs covered more topics, including those which appear to fall under the scope of PHPM programs, such as “the role of health departments in responding to climate change.” Other topics, such as those related to extreme cold or tornadoes, might be expected to vary among programs in different regions. The low level of curriculum content and variability in included topics suggest the benefit of a standardized climate change curriculum, which was largely supported by responding PDs.

The most frequent teaching method was didactic lectures, which may be a less effective teaching method for some topics. Although less reported, advocacy work may present a useful approach, as advocacy plays an essential role in affecting population-wide change. Physicians have a valuable or disproportionate role in advocacy for issues pertaining to health.

Surveys of emergency medicine and family medicine programs also noted limited inclusion of climate and health education.^20,21  A framework of climate change content that can be utilized across specialties, including learning objectives linked to Accreditation Council for Graduate Medical Education competencies, has been proposed.¹⁸  The American Public Health Association also provides content and strategies for climate and health education.⁷ 

This study’s limitations include the 49.3% response rate, without the ability to determine how the respondents resemble the total population of US preventive medicine residency programs. In addition, without further survey item validity testing, respondents may have interpreted questions differently than intended.

From these results, critical next steps may be to develop and test teaching and assessment strategies for core climate and health content, for PMPH, OEM, and AM preventive medicine programs.

This survey of US preventive medicine residency programs (PMPH, OEM, and AM) found that the vast majority included some climate and heath topics, but a formal curriculum was rare. There was wide variability among programs, despite most reporting interest in developing a common, standard curriculum.

The authors would like to thank the contributions of the program directors and associates who took the time to respond to this survey.

The online supplementary data contains the survey used in the study and a visual abstract.

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

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