Assessing Physician Climate Change Competency via Medical Licensing and Board Examinations: Lessons From Integrating Ultrasound Topics in Emergency Medicine Open Access

Apart from completing medical school and residency, the gold standard of demonstrating competency in the practice of medicine is medical licensing and board certification. Training programs are motivated to prepare their trainees to do well on board examinations, and board certification is associated with positive clinical outcomes for patients.¹  Thus, incorporating concepts related to climate’s impact on health in physicians’ certification/recertification examinations is a high-yield strategy for licensing bodies and specialty-specific certifying organizations working to equip the physician workforce with this critical, emerging body of knowledge.^2,3  This article examines the expansion of ultrasound topics in emergency medicine boards content to explore steps to similarly incorporate climate change topics in boards content more broadly. This analogy is particularly useful for examining the incorporation of core and cross-content climate change examination materials because climate change—like ultrasonography—has relationships with several organ systems/pathologies.

Board examinations have long signaled the value of addressing emerging health crises such as HIV/AIDS and risks such as vaping/e-cigarettes.^4,5  The question, then, is not whether board examinations should incorporate questions on climate and health, but how best to do so. The answer to this question may differ by medical specialty, but one practical example is the pathway employed by emergency medicine to incorporate the emerging role of ultrasound in in-training and board examinations.⁶  First, emergency medicine has worked to develop a scientific and practice-analysis-derived document that describes the domain of the field’s clinical practice, The Model of the Clinical Practice of Emergency Medicine (EM Model).⁷  The EM Model is developed in collaboration with 8 emergency medicine organizations across the trainee and practitioner spectrum (eg, the American Board of Emergency Medicine [ABEM], Council of Emergency Medicine Residency Directors, Emergency Medicine Residents’ Association, etc) and is reviewed every 3 years with representatives from each organization. All ABEM-developed examinations are based on a blueprint directly derived from the EM Model. One recommendation from the 2019 EM Model Review Task Force was the formation of an ultrasound working group. The recommendations of this working group informed decisions made by the 2022 EM Model Review Task Force, including expansion of the ultrasound section. In the 2019 EM Model, ultrasound was included under “Procedures and Skills Integral to the Practice of Emergency Medicine,” but was listed only as “diagnostic ultrasound” and “procedural ultrasound.”⁶  In the 2022 EM Model, the ultrasound section is more robust and explicitly includes core content areas like ultrasound physics and safety. The diagnostic and procedural ultrasound content has also been expanded to explicitly include specific organ system topics like pericardial fluid and pericardiocentesis in cardiac ultrasound.⁶ 

Two factors are apparent in the effective incorporation of emerging ultrasound topics in emergency medicine content and test blueprints: (1) a governing body that regularly reviews specialty core content and prioritizes important emerging areas, and (2) tangible action—via the formation of a working group—to help outline how to incorporate an emerging topic into specialty content. Many specialties have governing bodies to help determine core content. Often, these bodies are made up of practitioners in the specialty who rely on practice experience and other literature to determine salient topics. However, including resident and student trainees in this process is not always commonplace. Emergency medicine’s inclusion of trainees may be an important strategy for the incorporation of emerging topics.

One critique of adding new content areas is that there are already too many medical topics to be tested. It is estimated that the doubling time of medical knowledge was 50 years in 1950, but only 73 days in 2020.⁸  The body of medical knowledge has never been static; hence, as more salient topics are identified, other less salient topics are downgraded. We reiterate that climate change, one of the greatest health threats of the 21st century, is one of these salient topics³  and that fears of oversaturating tests with topics do not outweigh the risks of physician incompetence in this area. Moving forward, prioritization of climate change by specialty governing bodies that review board content will require continued advocacy by members of these specialties—including trainees—as well as the larger medical community.

After recognizing ultrasound as an important emerging topic, the recommendations by the ultrasound working group were critical to the tangible changes in the EM Model content, such that test approval committees could then begin their work of creating blueprints and examinations.⁶  For transparency, it will be useful for test approval committees of specialty certifying organizations to explicitly quantify the percentage of test contents allocated to climate change on blueprint tables moving forward. This may help uncover areas of climate curricula already included in tests and to what extent materials need to be added if grossly lacking.

Like ultrasound, test items for climate change will likely need to include a combination of core content and cross-content. Climate change corollaries to core topics of ultrasound physics or safety may include health care infrastructure vulnerabilities and health care industry/practice effects on sustainability. Health care as an industry is one of the leading contributors to greenhouse gas emissions, and policies are constantly being implemented in an effort to reduce health care’s carbon footprint.^9,10  Efforts to promote health care sustainability via the mitigation and proper disposal of health care waste is one such example that could be directly tested.¹¹  Cross-content questions may directly test a climate change topic as well as another core subject area. Although these will need to be determined by specific specialties, one could envision a climate change and cardiology question testing heart block and climate-related changes in the geographical distribution of Lyme disease risk^12,13  or a psychiatry question on how seasonal changes may potentially influence the timing and intensity of manic episodes in Bipolar I Disorder.^14,15 

In this article, we examined emergency medicine’s broadening of ultrasound topics in core specialty materials as a roadmap for other specialties to improve physician climate competency. Although we have focused on individual specialties, there is also an opportunity for improvements in general graduate medical examinations like United States Medical Licensing Examination Step 3. For Step 3, volunteer clinicians and educators make up Test Material Development Committees (TMDCs) that are responsible for the annual creation, review, and updating of test materials. Presently, there are TMDCs for topics like communications, but not climate change. Establishing a climate change TMDC for Step 3 may improve the climate conscientiousness of this examination. Furthermore, there remains an opportunity to garner cross-specialty buy-in from larger bodies like The American Board of Medical Specialties (ABMS). ABMS is the United States’ largest physician-led specialty certification organization, with 24 member specialty boards. In the past, ABMS has assisted specialties with establishing broad competency-based medical assessments and formative assessments for continuing education. Similar structures could be leveraged to facilitate the changes proposed for climate change in examinations.

In summary, climate change may not be considered a traditional subject in the practice of medicine, but this perception is changing. Climate change may soon join other topics like medical ethics that are understood as critical for physicians to understand and therefore routinely tested on certification examinations. Including climate change topics on medical board examinations incentivizes training programs to adopt these concepts in their curricula and primes trainees to incorporate this knowledge in their daily clinical practice to meet patient needs.