Incorporating Climate Change Education Into Residency: A Focus on Community Risks and Resources Open Access

Climate change (CC) is increasingly a focus in undergraduate medical education, yet it is rarely incorporated into graduate medical education (GME).^1-3  A 2021-2022 survey of 18 pediatric residency programs found that only one-third of programs had CC-related education activities, and a global survey in 2021 found that 3537 of 4654 health professionals (76%) felt the need for professional education on CC.^4,5  To educate the future physician workforce on climate health issues, effective GME climate education is needed.

Existing CC-related education in GME has varied content and is not well studied.⁶  Educators are currently exploring how to effectively teach residents CC-related health concepts that are relevant to their daily practice and commonly encountered clinical scenarios. Identifying essential content to incorporate alongside core curricula needs to be further studied.

To help address these issues, we created and implemented a new CC education session emphasizing anticipatory guidance, community resources, and advocacy opportunities for pediatrics, family medicine, and social medicine residents in a large urban academic health center. We evaluated the session’s effects on resident self-reported knowledge regarding the health effects of CC confidence in utilizing local CC anticipatory guidance and community resources in future medical visits.

A pediatric program with 74 residents and a residency program in social medicine (RPSM) with 72 residents (30 family medicine, 30 internal medicine in a social medicine track, 12 pediatrics residents in a social pediatrics track) participated. RPSM residents participate in curricular programs within their individual residency programs and also join multidisciplinary social medicine curricula designed for all 3 disciplines. All programs have social determinants of health and advocacy curriculum components and were felt to be the best fit for introducing this new education session.

Curriculum was developed by the first author in the 2022-2023 academic year using adapted learning objectives linked to the Accreditation Council for Graduate Medical Education (ACGME) Core Competencies.⁷  The education sessions included an introduction to CC and health with sections focused on specific CC health topics: extreme heat, air pollution and respiratory health, extreme weather events, mental health effects of CC, and advocacy opportunities. Topics were chosen based on the climate risk profile for the local communities in New York City using public health and local community-based organization (CBO) reports. Session content highlights principles of environmental racism and climate justice, with a focus on examples of integrating CC-related health risk discussions into physician-patient interactions (CC anticipatory guidance) and highlighting related local resources and community organizations for referral (CC community resources) or advocacy opportunities. The curriculum was created using Kern’s model and an iterative literature review process with feedback from regional environmental health experts.⁸  We estimate that performing the literature review and lecture building process required 30 hours of effort, with 1 to 2 hours of practice. See online supplementary data for content outline, learning objectives, linked ACGME Competencies, anticipatory guidance, and community resources covered during the learning sessions.

Four sessions covering the same content were completed; two 90-minute lecture-based sessions were incorporated into the social pediatrics and categorical pediatric residency curriculum and two 90- to 120-minute case-based sessions were included in the RPSM curriculum for family and social medicine residents (Figure 1). Small-group discussions in the case-based education sessions were followed by a full-group discussion of each topic and legislative advocacy opportunities. Education session formats were selected to fit each residency program’s learning model and embedded into existing curricula. One case-based session was conducted virtually due to COVID-19 precautions. Residents attended the sessions during their scheduled educational time and were eligible to complete pre- and post-session surveys only at the first session attended. Attendance was mandatory but research participation was voluntary.

The evaluation was conducted from February through November 2023 at an urban academic medical center. Pre- and post-session surveys were used to assess resident’s self-perceived knowledge of the health effects of CC and confidence utilizing CC anticipatory guidance and community resources in future medical visits. Differences between case-based and lecture-based learning format outcomes were also assessed.

The pre- and post-session survey instrument consisted of 5 questions adapted from previous studies.^4,5  There were 2 self-assessment questions assessing climate health content knowledge and 3 self-assessment questions assessing confidence utilizing content in clinical contexts (online supplementary data). A 5-point Likert scale was used for each question (totally disagree, somewhat disagree, neither agree nor disagree, somewhat agree, strongly agree). Given residency program leadership had knowledge of basic participant demographic data, and to prevent survey fatigue, participant demographic information was not collected to reduce survey length and improve the response rate.⁹  The survey was administered anonymously online using SurveyMonkey and utilized unique nonidentifiers to pair the pre- and post-session surveys. Participants received the pre-session survey at the beginning of the session and completed the post-session survey at session completion. One survey was used regardless of program or format given comparable content in all sessions. Participants received a $20 gift card as incentive for completing both the pre- and post-session surveys.

Participants self-reported changes in knowledge and confidence in the pre- and post-session surveys. Participants were considered knowledgeable and confident if they answered “somewhat agree” or “totally agree.” For statistical analysis, pre- and post-session survey results were coded (1=totally disagree, 2=somewhat disagree, 3=neither agree nor disagree, 4=somewhat agree, 5=totally agree) and mean average differences were compared using paired t tests.^10,11  Differences in survey response rates between case-based or lecture-based formats were assessed using a pooled t test. P values were considered significant if <.05. To detect a 25% or greater increase in resident confidence and attitudes after session completion, with a 2-tailed α error of 0.05 and 80% power, sample size was calculated at a minimum of 55 survey participants. Data skewness, kurtosis, and Q-Q plots supported use of parametric tests.

This evaluation received approval from the Albert Einstein College of Medicine Institutional Review Board.

A total of 108 out of 146 eligible residents (74%) participated in the new CC education session. Sixty-eight of 108 residents completed the pre- and post-session surveys (63% response rate). Eighty-three of 108 (77%) resident participants identified as women and 25 (23%) as men. Forty social and categorical pediatric residents attended a lecture-based session, and 28 family and social medicine residents attended a case-based session (Figure 1).

Of the post-survey respondents, 100% endorsed a good understanding of the effects of CC on human health, and 64 of 68 (94%) endorsed a good understanding of how CC impacts health care delivery. Sixty-four of 68 (94%) endorsed improved ability to discuss CC’s impact on health with patients, while 62 (91%) felt better prepared to provide CC anticipatory guidance. Fifty-nine (87%) felt prepared to connect patients with CC community resources (Figure 2).

After the education session, residents’ understanding of the health effects of CC were higher (mean difference 1.3; SD=1.10; t₆₇=9.85; 95% CI 1.04-1.57; P<.001). Residents rated their understanding of CC’s impact on health care delivery higher after the session (mean difference 1.5; SD=1.24; t₆₇=9.98; 95% CI 1.20-1.82; P<.001). Residents endorsed more confidence in discussing CC health effects with families (mean difference 1.8; SD=1.17; t₆₇=12.84; 95% CI 1.54-2.11; P<.001). Confidence in providing CC anticipatory guidance improved compared to pre-survey responses (mean difference 2.1; SD=1.07; t₆₇=16.25; 95% CI 1.84-2.36; P<.001). Resident confidence referring patients to CC community resources also improved compared to the pre-survey (mean difference 2.1; SD=1.07; t₆₇=16.28; 95% CI 1.86-2.38; P<.001). Increases in mean difference remained significant when grouped into lecture-based or case-based formats (Table), yet no significant difference was observed between the 2 learning formats (P=.55).

Resident participants in this CC education session endorsed improvements in knowledge of CC-related health effects and confidence in providing CC anticipatory guidance and community resources to patients after the session, regardless of format or residency program. These results are similar to other pre-post climate education surveys administered to pediatric and family medicine residents at other institutions.^12,13  While survey questions, content, and delivery style may differ, Sazegar et al also highlights the importance of providing local resources in CC education.¹³  Our evaluation adds to this growing data set and suggests that CC education sessions with locally focused content and resources may be an effective strategy to translate CC education frameworks into practice.

While the curricular framework we adapted suggests climate advocacy as an advanced learning objective, we believe it should be a core component of any CC education. Rather than a solely biomedical fact-based education model, CC education must increase environmental health awareness and promote transformative change.¹⁴  To prevent the worst CC health effects in our communities, we must prevent future warming from occurring, making advocacy essential. Local advocacy opportunities should be identified and offered to residents to build this skill set.

Robust climate and health data from local and state public health departments supported by CBO research informed the CC content in these sessions. In regions without similar data sources, national data networks can be used to create tailored CC education.^15,16  Residency programs can utilize national professional organization (eg, American Academy of Pediatrics, Society of General Internal Medicine, Society of Teachers of Family Medicine) resources when local CC CBOs are absent or lack resources.

Residency program educators can address the CC education gap by focusing content on local issues and solutions. Use of session templates supplemented by local data and resources could reduce pre-session preparation time and improve feasibility. Education sessions were added to these programs without eliminating other essential topics, but for educators with less curricular flexibility, specific components can be added into existing programming. For example, we are expanding CC education sessions into 3 additional residency programs in our center, requiring integration by highlighting CC links to health in specific topic areas such as heat-related illness and acute kidney injury. These education sessions focus on general preventative medicine guidance in each topic but lack dedicated sections on infectious disease, nutrition, and health care sustainability. As CC health literacy in trainees improves, these additional topics could be included in future iterations.

This evaluation was conducted at one institution and is limited by the inherent issues of self-reported pre-post survey assessments. A small sample size precluded analysis of responses based on sex; larger samples will allow for better analysis of any demographic differences such as race, gender, and prior environmental health or CC experiences. Given that CC health impacts are evolving, knowledge retention will require repetition. This was a complex intervention with 2 education formats that must temper conclusions from survey responses. Resident responses, and the dramatic shift in the post-survey responses, are subject to self-selection, social desirability, and satisficing biases, but could reflect that knowledge gaps were filled on a topic without significant prior exposure. Improved knowledge does not necessarily translate into behavioral change in clinical practice; thus, future assessments of climate-informed clinical care delivery are needed.

CC education should be part of a structured framework spanning undergraduate through continuing medical education. CC curriculum with multiple sessions and a broader evaluation framework including regular interval assessments spanning residency training is already in progress.¹⁷  Further study of optimal CC content, frequency of sessions, and standardized assessment strategies are needed. Clinical Competency Committees must review how trainees’ assessments will need to change to reflect practicing in a warming world.

Residents who participated in a lecture- or case-based CC education session on health effects tailored to local climate risks, anticipatory guidance, and community resources endorsed improved knowledge and confidence in discussing and providing CC resources to patients.

The authors would like to thank Maida Galvez, MD, MPH, Perry Sheffield, MD, MPH, Lauren Zajac, MD, MPH, and Sophie Balk, MD, for reviewing the manuscript prior to publication and for their advising on curricular development and all the residents at The Children’s Hospital at Montefiore and within the Residency Program in Social Medicine who participated in the sessions.

The online supplementary data contains education session materials and the survey used in the study with results.

Funding: Funding for this project was provided by the American Medical Association Reimagining Residency Initiative.

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

This work was previously presented as a poster at the Pediatric Academic Societies Meeting, May 2-6, 2024, Toronto, Ontario, Canada.