Climate Change Curricula in US Graduate Medical Education: A Scoping Review Open Access

The effects of a warming planet contribute directly to illness, including pulmonary disease, heart failure, atrial fibrillation, infectious disease, and cardiac arrest, with effects on more organ systems that are yet to be well defined.^1-5  With more severe and frequent extreme weather events, there will be increased strain on hospital systems, with mass casualty events affecting health care delivery. Additionally, physicians need to understand how climate-related health disorders disproportionately disadvantage groups such as minoritized and low-income populations.^6,7  Physicians are positioned to influence the social and policy landscapes to affect climate change.⁸  Patients can be empowered to understand the links between climate change and human health.³  The medical community must ensure that we educate future generations of physicians so that they understand their role in combating this threat. Ensuring trainees understand climate science and its interconnectedness with health is the first step in this process.

To highlight the urgency of this threat, the American Medical Association,⁹  the American College of Physicians,¹⁰  the American College of Emergency Physicians,¹¹  the American Academy of Pediatrics,¹²  and the Physicians for Social Responsibility¹³  have declared climate change to be a health emergency. There is a groundswell of activity at the undergraduate medical education (UME) level. However, little is known about graduate medical education (GME) climate change education.¹⁴ 

As the Accreditation Council for Graduate Medical Education (ACGME) has not included climate-related health competencies in its Common Program Requirements or specialty Milestones, programs may not perceive a need to address climate change within their curricula.^15,16 

To explore this apparent gap, we conducted a scoping review to examine if and how climate health education has been incorporated into US GME curricula. This topic lends itself to a scoping review as climate change education in medicine has been gaining momentum as a recognized and important component that will affect health care delivery in the immediate future.

The methodology for this scoping review was informed by the 5-step framework outlined by Arksey and O’Malley: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies; (4) data charting; and (5) collating, summarizing, and reporting the results.¹⁷ 

This review sought to answer the question, “How is climate change being incorporated into US GME program curricula?” The question further asked, “Which frameworks are being utilized; how is climate change being taught, and what are the existing gaps?”

With the assistance of a medical research librarian, we performed a literature search of English language articles from January 2013 to November 2023 using PubMed and Scopus. We chose this period as the United Nations extended the Kyoto Protocol in 2012 in response to a recognition of the urgency to act on climate change.¹⁸  The search terms and inclusion criteria are outlined in the online supplementary data Appendix 1 and were determined by an iterative process. The search was structured to capture articles that described topics relevant to climate change–related illness, policy, and quality improvement, in addition to incorporating terms to include education and curriculum design for US GME programs. Medical Subject Heading (MeSH) and controlled vocabulary terms were included as appropriate. Articles were not limited based on their type, and we included reviews, case reports, and descriptions of surveys. To ensure completeness, articles were included if they discussed curricula related to key topics relevant to climate change, including disaster medicine, mass casualty events, environmental medicine, public health, health policy, and wilderness medicine. As part of our iterative process, we also included articles that discussed quality improvement, climate resiliency, and sustainability.

To ensure adequate agreement for applying inclusion and exclusion criteria, 3 reviewers (A.C., S.K., R.H.) simultaneously assessed 20 randomly selected titles and abstracts. Disagreements were resolved by the senior reviewer (A.C.) after a discussion based on the inclusion criteria. This informed reiterations of our inclusion criteria for the review. During the first stage of the review, the 3 reviewers assessed the remaining titles and abstracts asynchronously, in equal proportion, and with articles blinded. During the second stage, A.C. reviewed the articles included in full. After this step, additional articles were excluded for not meeting inclusion criteria.

Three reviewers collaborated on relevant data points based on themes evident in the initial review of the articles. Data points included year of publication, type of article, method of data collection, country of origin, learner level, specialty, and specific topic(s) related to climate change. We stored these data in Microsoft Excel for descriptive analysis.

Articles were processed using Rayyan (Rayyan Systems Inc), and we utilized 2 distinct processes for collating and summarizing the charted data. First, a descriptive numerical analysis was performed for relevant data points, such as type of article, method of data collection, and topic(s) related to climate change. Second, the reviewers undertook a qualitative assessment of articles that described frameworks used to implement climate change curricula for GME programs. According to the methodology described by Mak and Thomas, stakeholder consultation is an important part of a scoping review.¹⁹  We chose a family medicine faculty member at an academic tertiary center in the Northwestern United States, who taught climate change and health in UME and GME. The insight gained from this stakeholder helped to inform the methods we chose for this scoping review. As a result of this consultation, we also included articles discussing sustainability initiatives as part of quality improvement.

Our initial search yielded 265 results after duplicates were removed. Of these, 248 records were excluded as they did not meet the defined inclusion criteria. We found another 5 articles through citation review that were deemed appropriate for full review. In the second stage of full article review, 5 articles were excluded for not meeting criteria. The remaining 17 articles were used for the review (Figure 1).

The final articles included secondary publications: reviews, perspectives, expert consensus statements (based on primary sources and curricula proposals), and descriptions of surveys. The most common type of article (5 of 17, 29%) was a description of a survey of program directors regarding the content of curricula (Figure 2).^20-24  The articles discussed climate change–related illness, public health, policy, disaster, environment, wilderness medicine, mass casualty incidents, quality improvement, and sustainability (Table).

Ten articles specifically mentioned climate change.^{1,3-5,22,25-29}  Seven did not mention climate change specifically but discussed a topic pertinent to climate change, such as disaster or tactical medicine (medical direction of law enforcement special operations).^{20,21,23,24,30-32} 

Emergency medicine was the most common specialty, with 8 included articles discussing how emergency medicine can incorporate climate change into curricula frameworks.^{3,20-24,29,32}  For disciplines, the next most common article group did not discuss a specialty but rather how climate change should be discussed in GME programs more broadly^4,5,27,30,31  (online supplementary data Appendix 2).

Three of the included articles reported outcomes from the described education or intervention.^1,22,28  One article discussed anecdotally positive experiences with generic climate change education.¹  Another discussed the increase in training opportunities in tactical medicine,³¹  and a third reported quantitative outcomes of changes associated with improved health care sustainability.²⁸ 

Vacharathit et al described how their continuous quality improvement curriculum had improved the hospital’s sustainability after 5 years of the program.²⁸  Projects were broken into 3 categories: water waste reduction, regulated medical waste reduction/pre-incision plastics recycling, and electrical energy usage reduction. As a result, they saved 20% of water waste, diverted 1 million pounds of plastics from landfills, and reduced CO2 equivalents per year by 717 metric tons over 5 years.²⁸  This article should serve as a standard for quantitative assessment for future sustainability projects.

Four articles served as calls to action for educators by describing content to be included in climate change curricula for GME programs, faculty, and trainees.^1,4,5,26  Each noted the importance of including climate change in GME training and used context through the lens of specialty ACGME core competency frameworks. Colbert et al outline how providing education in a transdisciplinary fashion will help to improve hospital-wide sustainability.⁵  Kuczmarski et al presented a novel framework that addresses climate change–related illness using an organ system approach, in order to be more easily incorporated into the existing internal medicine curriculum.¹  The article provided details on the evidence base to support the learning objectives. Kuczmarski et al also found that guest lecturers anecdotally reported positive experiences of the generic climate-related slides given to them to present during didactics.¹  Philipsborn et al provided a broad outline of the topics, with context, that should be included in the climate change curriculum and provides context for their inclusion.⁴  This article could serve as a resource for programs looking to build a curriculum in climate change and health.⁴  Goshua et al discuss the need to include climate change education in GME pediatric programs.²⁶  Similar to the other articles, they provide a comprehensive assessment of the topics that should be included in the curriculum for pediatricians. They also gave examples of how some US GME programs incorporate climate change education into their curricula.²⁶ 

In this scoping review of literature related to GME curricula in the United States, we identified numerous gaps in the literature so that future research teams can focus on projects to understand how best to incorporate climate change education into US GME programs.

This scoping review found that the field of climate-related health curricula is in its infancy, with few relevant publications. Articles were predominantly surveys of program directors, descriptions of curricula, and calls to action. Overall, the quality of the existing information is considered low at this time. For example, the few articles that address the effectiveness of curricula do so through learner satisfaction assessments rather than external assessments. The 4 articles that we defined as calls to action give examples of how programs could utilize curricula but are missing objective assessment of effectiveness in helping learners better understand climate change and health. They are similar in that they give a structured way to discuss the relevant components of climate change as it relates to health and could serve as a standard for creation of curricula in GME programs; however, without outcome data on learner knowledge improvement to support efficacy, recommendations to utilize these frameworks remain difficult.

Climate change and health is a fast-moving field that prominent medical organizations have identified as an area of urgent need to address. Based on this scoping review, there are limited accounts of how incorporating climate change curricula into GME programs has been done, let alone reporting on the knowledge improvement for learners. Climate change can be an abstract topic for programs to incorporate into already busy curricula schedules. We must work as a field to keep pace with up-to-date literature to educate learners to face the challenges of climate change as it relates to health.

This review is limited by the focus on English language and US programs, which may omit important international work in GME and climate-related health. Also, there may be key articles published since the fall of 2023, as well as other topics relevant to climate change that were not included in this review. The lack of formal program evaluations of GME curricula related to climate change and health limits this review. The articles that address the effectiveness of their curricula do so through learner satisfaction assessments, a relatively weak way to assess the efficacy of a curriculum. This limitation highlights an avenue for future scholarship in that researchers and educators should seek to assess how effective climate change curricula are at improving learners’ knowledge before and after incorporating changes.

Future scholarship should focus on reporting how climate change is incorporated into GME curricula. These reports should include examinations of feasibility, acceptability, and assessments of how curriculum changes improve learners’ knowledge and skills in the area of climate change and health. Examples include formal program evaluations examining the efficacy of curricular changes, well-designed studies examining learners’ knowledge and skill related to climate and health, and reports on the results of quality improvement projects focusing on sustainability. Figure 3 summarizes the findings of this scoping review with a wide lens to allow readers to use this work as a launch pad for future endeavors.

This scoping review found few descriptions of curricula and few evaluations of these curricula in US GME programs. The specialty of emergency medicine was the target for nearly one-third of articles. Most articles were surveys of program directors, and most articles suggested that climate change will create significant challenges for providing high-quality health care. The direction of future research should focus on the efficacy of climate and health curricula by using measurable outcomes to aid GME programs in the creation, adoption, and implementation of such curricula.

The authors would like to thank medical librarian Laura Zeigen, MA, MLIS, MPH, who helped the team develop and conduct the search strategy, and Lalena Yarris, MD, MCR, for reviewing the manuscript and providing advice on composition and structure to improve the rigor of our submission.

The online supplementary data contains further data from 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.