A Graduate Medical Education Fellowship in Climate Change and Human Health: Experience and Outcomes From the First 5 Years Open Access

Climate change is an escalating health threat that many physicians and health care organizations are poorly prepared to face.^1-4  The urgency of educating health care professionals on this topic is becoming increasingly clear.^2,5 

To address this need, a wide variety of educational approaches are being explored. These include lectures, short courses,^6,7  continuing medical and nursing education programs, integration of content into medical school and residency curriculum,^8-10  and the development of certificate, diploma, and fellowship training programs focused on climate change, health, and health equity.^5,11  These programs are often presented in an online format, and in most cases are not structured as formal graduate medical education (GME) fellowship training programs at health care institutions.

However, in-person GME programs have an important role to play. A hallmark of GME is the combination of an educational structure with an apprenticeship model¹² ; future leaders in climate change and health care can benefit from training, experience, and mentorship that prepare them for careers conducting original research, educating others, leading projects and organizations, and communicating with patients, peers, policymakers, and the public.^5,13  While early results are promising, the effects of climate-focused GME fellowships on the professional trajectories of trainees are still being quantified.^5,14 

Here, we describe our experience developing and implementing a full-time, in-person GME fellowship designed to train physician leaders in climate change, and present outcomes from the first 5 years of the program.

Our fellowship was implemented in 2019 at an urban academic teaching hospital in collaboration with 2 university-affiliated academic centers. Participants were emergency medicine physicians from the United States and abroad.

Fellows complete either a 2-year program with integrated Master of Public Health (MPH) and clinical practice, or 1-year program with additional research time. Components include fellowship classroom activities, longitudinal mentorship, original research, communications training, participation in national and international conferences and policy forums, and externships with relevant agencies and organizations (Table 1).

Program completion, professional roles following program completion, and professional outputs were assessed for each fellow. Professional output categories included academic outputs such as peer-reviewed journal articles; professional or academic talks; poster presentations; and grants; as well as public outputs such as educational activities for trainees, peers, and the public; public speaking; policy activities; media appearances; and other articles. Outputs were collected for 36 months before and after fellowship matriculation and are either publicly available or documented in the proceedings or agendas of relevant institutions or conferences. Results reported are through December 2023.

Program development and implementation are presented via narrative report. Professional outputs for each fellow were cataloged by date and type. Mean monthly outputs in the pre- and post-matriculation periods were computed. Normality of distributions was assessed via Shapiro-Wilk tests. Differences were assessed via paired t tests and confidence intervals computed via t distribution. Proportions of climate-related outputs were compared via Chi-square tests. Analysis was conducted in MS Excel v16.80 (Microsoft 365) and R v4.2.2 (R Project).

This report does not constitute human subjects research (Beth Israel Deaconess Medical Center Institutional Review Board Determination #2023D001138).

The fellowship was implemented in 2019, after engagement with individuals experienced in program development, including an existing climate change GME program,^5,11,13  climate and health policy,¹⁵  and disaster and humanitarian medicine.¹⁶  The result was a 2-year program integrating an MPH, longitudinal clinical practice, fellowship classroom activities, research, and externships at government and nonprofit organizations. The fellow’s primary appointment was at the teaching hospital, while participating academic centers (climate change, human rights) provided desk space, access to and mentorship from faculty, and communications support.

Following completion of the fellowship by the first fellow, lessons learned were assessed, and the program entered a period of refinement and expansion. The main foci that were identified included (1) the necessity for a more comprehensive didactic curriculum that provided foundational content and flexibility to address knowledge gaps for individual fellows; (2) the need for formal communication training prior to media and public engagement; and (3) demand for a 1-year fellowship option to accommodate diverse needs of learners and improve accessibility to the program. Following graduation of the second fellow and completion of a first year of training by a third fellow, additional feedback was solicited. Fellows felt their content knowledge was solid and suggested refocusing more time on projects and collaborations; this feedback led to increased emphasis on longitudinal mentorship for external projects on topics of specific interest and reduced emphasis on guest lectures and didactics.

Formal communications and media training was integrated to prepare fellows for public engagement opportunities. This now includes foundational media training with communications experts, mock interviews and roleplay exercises, and ongoing feedback for fellows following interviews and some public speaking engagements. The didactic curriculum was expanded and formalized, utilizing a combination of core curriculum with program faculty, guest lectures, and journal clubs. Given the broad scope of climate change and its intersection with health, it was important to establish a curriculum that provided a basis for understanding climate science and impacts on health and health care delivery, while offering flexibility for fellows to explore specific areas of interest or to address knowledge gaps. To make the fellowship accessible to international applicants, a 1-year, nonclinical, nondegree track was offered with an emphasis on development of climate change expertise and a research and communications portfolio. More recently, climate tracks have been created for individuals completing fellowships in infectious diseases or disaster medicine in collaboration with their program leadership, which will be described in future articles.

Initial departmental support and external philanthropic support was essential for the initiation of this program. The costs and nonfinancial inputs associated with implementing and sustaining our fellowship are salaries and cost of living, faculty time, support staff in research and communications, research and publication costs, travel costs for conferences, externships, and policy-related activities. These are supported through a combination of clinical revenue, foundational support, grant funding, departmental support, and in-kind contributions. Clinical revenues cover base costs for clinical emergency medicine GME fellows; program operational costs and additional project or travel costs are supplemented via external philanthropic and competitive grant funding.

Five fellows have matriculated; 3 remain enrolled in the fellowship, and 2 have completed the program. Fellows have spoken at international forums including United Nations Conferences COP27 and COP28. One graduate serves as the climate and health lead for a Ministry of Health; the other is Director of Healthcare Solutions at a climate and health center.

Fellows produced an average of 0.26 outputs per month during the 36 months preceding fellowship matriculation (95% CI 0.01-0.51) and produced an average of 2.13 outputs per month following fellowship matriculation (95% CI 0.77-3.50). This difference was significant at alpha=0.05 via paired t test (P=.01); (Table 2). Subanalysis of academic outputs revealed similar increases in productivity (Table 2). Prior to matriculation, 32 out of 48 outputs (66.7%) were climate related; after matriculation, 186 out of 191 outputs (97.4%) were climate related; this difference was statistically significant (continuity corrected Chi-squared 41.4; P<.01).

Our fellowship in climate change and human health has leveraged mentorship, research, and communications resources to support academic and public engagement as we prepare physicians to take on leadership roles related to climate change. We have seen increased professional productivity in both public and academic domains following fellowship matriculation.

GME fellowships provide physicians with protected time and resources to develop critical knowledge and specialized skills. This model has been implemented in other nonclinical domains—including global health,¹⁷  medical education,¹⁸  research, and health care administration—and has shown benefit in guiding career trajectories and preparing individuals for faculty appointments.^18,19  The productivity increases seen in our climate fellowship cohort are promising; outcomes will need to be followed longitudinally to better understand long-term impact.

Several key factors were instrumental in the implementation of our fellowship. Institutional support for novel educational programming, external funding, and the involvement of collaborating academic centers with complementary resources has sustained the program and broadened opportunities for trainees. Research and externship projects have helped fellows prepare for leadership roles in specific geographical or institutional settings.

Organizations assessing the feasibility of implementing a similar program may wish to consider availability of mentors with relevant expertise, availability of dedicated departmental or external funding, availability of nonclinical centers that can provide additional resources, and availability of research and communications support resources, including statistical support, communications specialists, and other nonfaculty resources that will enhance trainee effectiveness.

Due to small sample size, observed findings may be subject to influence from individual observations. Ongoing projects, proposals, and manuscripts under review were excluded; projects started before matriculation were analyzed by publication date. This pre/post analysis cannot eliminate covarying factors affecting professional productivity and does not adjust for variation in activities preceding fellowship.

Five fellows have enrolled in this GME climate change fellowship. Academic and public output rates increased following fellowship matriculation.

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

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

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the South Australian Department for Health and Wellbeing, or the South Australian Government