Climate Change Curriculum in a Network of US Family Medicine Residency Programs Open Access

The climate crisis will undermine decades of global health progress and disproportionately impact vulnerable populations.^1-3  Providing adequate climate-related training to health professionals is a workforce preparedness issue with significant public health implications.⁴ 

Practicing health care professionals from around the world feel they lack sufficient training and education to engage effectively around climate change.⁵  Researchers have found a gap between the perceived value of similar (environmental health) content and the actual integration of such content within the curriculum of some family medicine residency programs.⁶  A variety of health professionals have identified inadequate time for curriculum development, competing institutional priorities or politics, lack of interest from trainees, and skepticism about climate health science as barriers to the inclusion of climate change in the curriculum of their training programs.⁷ 

Experts have made a strong case for integrating climate change into residency and postgraduate medical education.^8,9  With their broad scope of practice and focus on health equity and interdisciplinary care, family physicians are particularly well-positioned to mitigate the crisis’ far-reaching health impacts.^10,11  However, little is known about how much family medicine residency programs cover climate change in their training, how those programs provide such curriculum currently, or how their residents and faculty feel about it.

The objectives of this study were to: (1) determine the extent to which climate change is currently integrated into family medicine residency curricula, and the extent to which faculty and residents desire such content; (2) identify barriers which prevent integration of climate into the curriculum; and (3) identify climate-related content areas, delivery methods, and program actions most preferred by family medicine residents and faculty.

In fall 2021, an anonymous online survey was distributed to residents and faculty of 31 family medicine residency training programs (48 training sites) located within the states of Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI network).¹²  Training sites varied considerably in size, with some having only a handful of residents and faculty, and others having up to 36 residents plus instructors. According to WWAMI Family Medicine Residency Network leadership, there were approximately 700 residents and 575 core faculty affiliated with the network at the time of data collection.

The researchers, family medicine educators interested in climate and health, developed the 25-question, anonymous survey using an iterative process. Specifically, they reviewed the current literature and related survey instruments, and then drafted questions more appropriate to their objectives. Although the survey was not formally piloted, feedback on question content and clarity was sought from colleagues, and the instrument was revised accordingly before distribution.

The final survey utilized Likert scales to assess the extent of current and desired climate-related training provided in a respondent’s program, and drop-down menus and frequencies to assess perceived barriers to inclusion of climate curriculum, preferred climate-related content and teaching methods, preferred actions to be implemented by a respondent’s program to address climate change, and respondent demographics. The survey (provided as online supplementary data) was constructed utilizing Qualtrics Survey Software (Qualtrics).

The program directors of all network programs were asked to email the survey link to their residents and faculty, a pool of approximately 1275 possible respondents. After a first round of data collection, they recirculated the recruitment email and shared the link via the network’s faculty listserv. Participants provided consent when opening the survey, making them eligible to win 1 of 3 $100 gift cards. Data were collected between November 1, 2021 and January 1, 2022.

The data were analyzed using SPSS software, version 27 (IBM). The extent of current and desired curriculum was measured on a 5-point Likertscale in which 1=“none at all,” 2=“a little,” 3=“a moderate amount,” 4=“a lot,” and 5=“a great deal.” While these outcome variables were categorical in nature, prior research has demonstrated that ordinal variables with 5 or more categories may be treated as continuous variables, facilitating the ease of interpretation of findings.¹³  Consequently, a paired samples t test was used when comparing extent of current and desired climate-related curriculum. Drop-down menus were provided and frequencies were calculated to identify the top barriers to a climate curriculum, most frequently selected areas of curricular content, most frequently selected content delivery methods, and most frequently selected climate actions to be taken by residency programs.

Institutional review board exemptions were received from the University of Montana and Johns Hopkins University on September 20, 2021 and October 22, 2021, respectively.

A total of 233 individuals completed the entire survey, and another 13 finished at least 25% of the survey (48.5%, on average), for a response rate of 19.3% (246 of 1275).

Demographic questions were located at the survey’s end, so most non-completers did not answer (all of) those questions. Out of 246 survey respondents, 232 (94.3%) indicated whether they were residents or faculty members. Respondents represented all 5 states and at least 35 of the 48 (72.9%) training sites affiliated with the network at that time. Thirteen respondents (5.3%) left the program affiliation question blank. Faculty responded from 32 of the 48 (66.7%) training sites, and residents responded from 14 (29.2%). Additional demographic data regarding participant sex/gender, age, and race/ethnicity appear in Table 1.

Out of the 240 respondents who answered the question, just over half (54.6%, 131 of 240) indicated that climate change appeared somewhere in their programs’ curricula. However, only one-tenth (10.4%, 25 of 240) reported “a moderate amount” or more of climate-related content, and only 2 respondents (0.8%) indicated that their programs provided “a great deal” of climate-related training. Faculty and residents did not differ in their perceptions of current content (M_F=1.61; SD_F=0.64; M_R=1.74; SD_R=0.866; t[230]=-1.29; P=.20).

Out of the 238 respondents who answered the question, close to three-quarters (71.0%, 169 of 238) desired at least “a moderate amount” of climate-related content in their programs’ curricula (see Table 2). Overall, respondents desired significantly more climate curriculum (M=3.02, SD=0.99) than is being provided currently by their programs (M=1.68; SD=0.77; t[237]=18.17; P<.001; 95% CI 1.19-1.48; Cohen’s d=1.18). Faculty and residents did not differ in their preferences (M_F=3.06; SD_F=0.944; M_R=2.98; SD_R=1.013; t[230]=0.603; P=.55).

Respondents were most likely to select “insufficient time/competing curricular priorities” (80.7%, 192 of 238), “lack of faculty or resident ‘champions’” (57.6%, 137 of 238), and “inadequate training materials” (46.6%, 111 of 238) as top barriers to having more climate-related curriculum in their programs (see Table 3). Notably, over a quarter of respondents (27.3%, 65 of 238) felt the political/controversial nature of climate change was a top barrier for their programs, and a minority (10.9%, 26 of 238) felt their programs see climate change as irrelevant to family medicine training.

Between 44.3% and 66.2% (105-157 of 237) of respondents selected each of several climate-related topics for inclusion in their program curricula (see Table 4). Desired content extended beyond direct patient care to include community education and advocacy, community and health care system adaptation, disaster planning, and environmental stewardship.

When considering ways to deliver climate-related curriculum, respondents were most likely to express interest in integrating such information throughout relevant didactics (62.2%, 145 of 233), followed by integrating climate-related tools and “pearls” into clinic precepting (54.9%, 128 of 233; see Table 4). However, even the most labor-intensive option (a “climate change and health elective”) was selected by 30.0% of the respondents (70 of 233).

Finally, between 42.5% and 60.5% (99-141 of 233) of respondents selected each of the suggested climate-related actions that could be implemented by their residency programs (see Table 5). These included community events/projects, quality improvement projects, and several ways to reduce the climate-related impacts of residency programs and personnel.

The literature emphasizes the need for inclusion of climate-related content into residency training.^8,14  In one study of pediatric residents and program directors, 76% of residents surveyed “strongly agreed” that a climate change curriculum should be incorporated into their training program, but only one-third indicated that their training programs currently included such content.¹⁵  In another study, approximately one-quarter of family medicine residency program directors surveyed reported that their curricula included climate content, though minimally.¹⁶ 

To the researchers’ knowledge, this study was the first to ask family medicine residents and faculty how much and what kind of climate content they desire, and how they would like that content delivered. Just over half (54.6%) of respondents indicated that climate change appeared somewhere in their program’s curriculum, which is consistent with recent studies of medical school curricula.¹⁷  Nonetheless, that content was minimal for 9 out of 10 respondents, and both residents and faculty expressed a strong desire for more climate curriculum. Indeed, the significant gap between what is currently available and what study participants thought should be offered is a call to action for graduate medical education (GME) program directors and their institutions.

At the same time, the findings highlighted several barriers that make it more challenging to include climate-related content in residency training. In particular, the vast majority of respondents identified “insufficient time/competing curricular priorities” as a top barrier, which may help to explain why 21.6% of resident respondents also identified “insufficient resident interest” as an important barrier in their programs. Lack of perceived interest may also reflect a self-reinforcing “spiral of silence,” whereby even those who care about the climate crisis avoid discussing it because others around them are silent.¹⁸ 

Other responses highlighted the need for curricular champions, institutional support, and training materials. Fortunately, there are efforts underway to train climate and health “ambassadors,”¹⁹  provide plug-and-play training materials that can be readily integrated into residency didactics,²⁰  and define discrete learning objectives for climate-related GME training (Bhargavi Chekuri, MD, email communication, August 11, 2023). GME will also benefit from overarching guides and blueprints for mapping climate-related health education to trainee level, and an investment of time and resources for faculty development. If the Accreditation Council for Graduate Medical Education were to include climate change in their competencies, that would also encourage institutions to prioritize and support such training.

Minorities of both residents (33.6%) and faculty (21.6%) perceived that the political/controversial nature of the topic makes it difficult to integrate climate change into their programs’ curricula. This is perhaps not surprising, given tensions within US society in 2021 during the COVID-19 pandemic and the challenges of communicating science in politicized environments.²¹  For example, one faculty member (#085) shared that addressing climate change would be “politically difficult… We cannot even get our population to vaccinate or mask.” For productive and effective learning, it will be important for programs to engage sensitively around climate change, just as they do other controversial topics (eg, anti-racism, abortion, and transgender care).

Finally, study findings demonstrated that doubt about the relevance of climate change to health persists, even among health care professionals. In fact, 10.9% of respondents selected “Irrelevance (ie, climate change doesn’t belong in the curriculum)” as a top barrier in their programs. One faculty respondent (#003) dismissed the survey as “useless and politically driven,” another (#122) cautioned, “Until we know the scope of impact, if any, it would be premature to displace current curricular elements to a significant degree,” and a resident (#091) similarly noted, “If any curriculum changes are made, I would hope the emphasis is on evidence-based, health-related and relevant information.” These comments are concerning, given the large and growing body of scientific evidence around the health impacts of climate change,^4,22  a 2019 American Medical Association resolution to include climate change in medical school and graduate education,²³  and a recent American Academy of Family Physicians position paper on the importance of climate change and environmental health to human health.²⁴  Faculty and program administrators clearly need to disseminate the evidence and carefully address those barriers that are most prominent in their own residency programs and specialty areas as they boost climate-related curricula.

Study participants provided important feedback regarding preferred curricular content and methods, as well as climate-related actions to be taken by their training programs. Respondents recognized that a breadth of content is needed to address all of the ways that climate change will impact health, and the multiple roles that family physicians and health care systems can play in its mitigation.²⁵ 

Integrating climate content throughout the curriculum, the approach currently championed by the Climate Resources for Health Education initiative of the Global Consortium on Climate Health Education,²⁰  appears to be the best response to concerns about limited time and competing curricular priorities. Importantly, however, the study findings suggest that climate-related training can also take place in the community (eg, through civic engagement, partnerships, or coalitions) or via other program requirements (eg, advocacy, quality improvement projects). Indeed, a high percentage of respondents recognized the importance of communicating with patients about climate change and its impacts on health, working to reduce their own environmental “footprint” through sustainability and stewardship efforts in their practice environments, and engaging in community education and advocacy efforts to broaden their impact.

Institutional cultures, community politics, and program personnel vary. Respondents identified different “top” barriers in their programs, and there is no “one-size-fits-all” solution for how to integrate climate into the curriculum of any given family medicine residency program. Nonetheless, the researchers anticipate that these findings will provide useful ideas and guidance to residents, faculty, and administrators working to enhance their GME programs’ climate-related training.

The survey instrument was developed for this study. Despite efforts to strengthen content and face validity, some respondents could have interpreted questions differently than intended.

The residency network through which the survey was distributed does not collect consistent demographic data, so the extent to which respondents were representative of the network as a whole is not known. Further, the potential underrepresentation of respondents from some training sites (including several rural training tracks and smaller sites) and a response rate of <20% could further limit the generalizability of the findings. For example, it is possible that respondents from more rural or conservative areas would have been less likely to recommend climate education or more likely to consider it controversial or irrelevant. Residents and faculty experiencing greater concern about climate change may also have been more likely to respond to the survey.

It is also possible that the survey’s timing and the location of participants influenced the findings, as the regions in which the network programs are located experienced significant heatwaves and wildfires in the months just prior to data collection. Given projections that climate change and its health impacts will only increase in future years,⁴  however, the need for climate-related curriculum in GME will likely only grow.

To test the generalizability of these findings, it will be helpful to collect post-COVID-19 Public Health Emergency data from family medicine residencies across the country, and to explore further some of the differences in perception between residents and faculty. It will also be important to solicit input from residents and faculty representing different GME specialties or subspecialties to appraise their programs’ current commitment to climate change education, determine if similar barriers to climate-related curriculum exist in all specialty areas, and assess how climate-related curricula should be tailored to best prepare their graduates for the climate-related health challenges that lie ahead.

Study respondents indicated that the climate-related curriculum to which they are currently exposed is insufficient. They identified current barriers and ways to integrate climate broadly throughout graduate medical training.

The authors would like to acknowledge Bhargavi Chekuri, MD, Co-Director of Diploma in Climate Medicine, University of Colorado; Nancy Newman, MD, Faculty, Hennepin Family Medicine Residency; and Megan Weil Latshaw, PhD, Associate Scientist, Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health.

The online supplementary data contains the survey used in the study.

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

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