Introduction
A 45-year-old man presents to his physician for potential adjustment of his blood pressure medications. He mentions that he has been having worse headaches recently. Concerned, he went to the emergency department, where he was evaluated and advised to follow up with his physician for further assessment of his hypertension and to optimize his current medication regimen. The weather has been unusually hot, and given the increasing recent heat waves, the physician is now routinely asking patients if they have a way to stay cool at home or at work on hot days. The patient states he has air-conditioning at home but has difficulty staying cool at work while working as a roofer. He explains that he gets a water break every 2 hours and has access to shade only during lunch breaks.
Often patients do not recognize the relationship between symptoms and their environment, and even when recognized, may not have the ability to change their environments. Clinicians across specialties often see patients with heat-related illnesses, but they may have lacked training during residency or fellowship, and may still lack resources to adequately diagnose and counsel patients. Clinicians who are able to recognize and manage heat-related illnesses could provide guidance for this patient, including recommendations on best cooling practices and hydration. While health effects of climate change affect almost every medical specialty, occupational and environmental medicine (OEM) specialists bring specific expertise about the impacts of environmental exposures on health and can offer targeted individual and population solutions to manage and prevent conditions caused or exacerbated by climate change.1,2
Role of OEM Physicians in Workplace Mitigation and Adaptation to Climate Change
OEM is an Accreditation Council for Graduate Medical Education–accredited medical specialty that focuses on health outcomes linked to workplace and environmental exposures, including climate change. The specialty encompasses the fields of public health, epidemiology, toxicology, and industrial hygiene to assess, manage, and prevent occupational health issues, including work causation, fitness for work, impairment assessment with suggested reasonable accommodations, surveillance for work conditions, and preventive measures like immunizations and personal protective equipment (PPE).3 OEM training also includes considerations of community environmental health, environmental and social justice, and attention to the broader ecological and planetary context. OEM residency training requires at least an initial clinical training year accredited by the ACGME before entering the 24-month residency program. Training consists of a mixture of clinical and practicum experiences to address OEM competencies. Trainees are required to complete a Master of Public Health or equivalent degree as part of their training if they do not already hold one.
OEM specialists identify and mitigate workplace hazards and collaborate with stakeholders (workers, employers, and relevant agencies) to ensure a safe working environment. This includes knowledge of the federal and state laws and regulations that protect worker health and the environment, as well as public health guidelines.1,2 OEM specialty training teaches a unique set of skills critical for addressing climate-related health impacts through a population health lens.
OEM specialists assess worksite and community exposures using a “hierarchy of controls” (HOC) to reduce and prevent risk (see Figure).4 This HOC may involve redesigning the work environment where possible, implementing engineering and administrative measures, developing medical surveillance programs, and educating workers and supervisors on the use of PPE and other control measures. Fundamentally, the HOC incorporates the concept of various levels of prevention. In climate-related health conditions, “elimination” of the hazard could involve greenhouse gas reduction at the highest possible level. It could also include strategies to cool communities by addressing the urban heat island effect, such as increasing tree canopy or using cool pavements.
NIOSH Hierarchy of Controls With Climate Change Examples
Abbreviations: NIOSH, National Institute for Occupational Safety and Health; PPE, personal protective equipment.
NIOSH Hierarchy of Controls With Climate Change Examples
Abbreviations: NIOSH, National Institute for Occupational Safety and Health; PPE, personal protective equipment.
Our case: The physician is concerned about the patient’s working conditions but is not sure about the regulatory norms in the roofing industry or how to approach the employer with these health and safety concerns. The physician refers the roofer to an OEM specialist for assistance with worker accommodations. The OEM physician takes a comprehensive medical history, including an occupational and environmental health history. They determine that the patient has been having symptoms of heat-related illness and is at risk for a more severe heat injury due to underlying hypertension. They are also aware that the patient’s coworkers are at risk for heat-related illness and that their state recently passed an occupational heat stress standard that requires proactive measures to protect workers from heat-related illness. The OEM physician prepares medical documentation to support all the necessary actions to prevent a heat-related illness, notifies the employer about the heat stress standard, and provides specific recommendations consistent with the new law, requiring shade, water, and rest when the temperature reaches specific thresholds, to protect all the workers. A heat stress “toolbox talk” is shared by the OEM physician with the employer to use to educate supervisors and workers, as well as information about the Occupational Safety and Health Administration–National Institute of Occupational Safety and Health (OSHA-NIOSH) Heat Safety Tool app that can be downloaded to a smartphone, which offers real-time outdoor heat and humidity readings, warning levels, symptom lists, and first aid measures.5
Integration of Climate Health Education Into Graduate Medical Education
All graduate medical education (GME) programs should systematically address climate health education by advocating for program-specific competencies and milestones. Utilizing the Global Consortium on Climate and Health Education core physician competencies, additional language can be proposed to relate to specialty-specific domains.6
OEM specialists can be a resource to GME programs by creating and integrating climate health curricular topics and by helping develop competency frameworks for hazardous exposures from climate events. OEM training programs can also provide specialized training to other GME programs on risk assessment and applying the HOC approach.
A unique feature of OEM training programs is the incorporation of worksite or environmental site visits for direct observations of occupational and environmental practices in various industries, which can include assessments of work practices relevant to climate change mitigation. GME programs could partner with OEM programs in joint worksite visits, to foster interprofessional discussion around climate change effects and mitigation.
OEM physicians work closely with industrial hygiene, safety, nursing, epidemiology, and public health professionals; therefore, many OEM programs have developed interdisciplinary conferences to review clinical cases and discuss best practices. This model can be expanded to other GME programs in collaboration with OEM faculty, to focus on climate change and health. The shortage of knowledgeable faculty is a barrier to adding residency curricula on climate-related health effects, and collaborations with OEM faculty and trainees may address this barrier.7
Trainees in other residency pathways could work with OEM faculty and trainees on joint quality improvement projects, offering synergy and broadening perspectives. Projects could address sustainability, develop clinician educational programs, and target vulnerable populations’ needs. Additional suggestions are provided in the Table.
OEM is at the forefront of transforming climate health education with expertise in working with communities, workplaces, and public health. The evolving climate crisis offers numerous, largely untapped opportunities for OEM faculty and trainees to partner with other specialties in developing curricula and clinical experiences. With OEM collaborations, other GME programs will gain resources for training future physicians to prevent and mitigate climate-related illness, be a resource to patients in adapting to climate change, and promote well-being by leveraging technology, environmental awareness, and collaboration between health care, workplaces, and communities.
The authors would like to acknowledge the following individuals, who helped formulate the ideas presented in this article, and who continue to help develop specific recommendations for modifications to the curriculum of Occupational and Environmental Medicine residents to prepare them to lead climate change-related health efforts: Stefan Wheat, MD, Assistant Professor of Emergency Medicine, University of Washington School of Medicine; Oladele Ogunseitan, PhD, MPH, Distinguished Professor, Department of Population Health and Disease Prevention, and Department of Environmental and Occupational Health, University of California, Irvine; Samantha Ayoub, MD, MS, Addiction Medicine Fellow, Department of Preventive Medicine, Loma Linda University; Peter Rabinowitz, MD, MPH, FAAFP, Professor, Department of Environmental and Occupational Health Sciences, Department of Global Health, University of Washington School of Public Health, Department of Family Medicine, University of Washington School of Medicine; Bhargavi Chekuri, MD, Co-Director of Climate and Health Science Policy Fellowship, Co-Director of Diploma in Climate Medicine, Assistant Professor of Family Medicine, University of Colorado School of Medicine; and Cecilia Sorenson, MD, Director, Global Consortium on Climate and Health Education, Columbia University, Associate Professor, Department of Environmental Health Sciences, Mailman School of Public Health, Associate Professor, Department of Emergency Medicine, Columbia University Irving Medical Center.
References
Editor’s Note
The online supplementary data contains a visual abstract.