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Climate Change, Environment, and Health: The implementation and initial evaluation of a longitudinal, integrated curricular theme and novel competency framework at Harvard Medical School [1]

['Madeleine C. Kline', 'Harvard Medical School', 'Boston', 'Massachusetts', 'United States Of America', 'Harvard T.H. Chan School Of Public Health', 'Julia R. Malits', 'Department Of Emergency Medicine', 'Massachusetts General Hospital Brigham', 'Women S Hospital']

Date: 2024-06 

Abstract Climate change, air pollution, and ecological degradation impact health through numerous, complex mechanisms. To train future physicians to understand these impacts, medical schools can deliver longitudinal climate curricula in undergraduate medical education, but the field remains nascent. This report describes the development, implementation, and evaluation of the longitudinal, integrated Climate Change, Environment, and Health curricular theme and novel competency framework at Harvard Medical School (HMS). A group of HMS students collaborated with faculty to integrate climate content into the pre-clerkship curriculum. The team subsequently pursued institutional recognition as a formal HMS curricular theme and created a new competency framework that guided curriculum integration mapping and evaluation tool development. The competencies cover the impact of climate change, air pollution, and ecological degradation on health in the context of historical and structural inequities and explore the role of healthcare in contributing to both climate change and solutions. A retrospective, eight-item survey using a seven-point Likert scale and two open-ended questions was administered at the end of the pre-clerkship curriculum. HMS approved a required, four-year Climate Change, Environment, and Health curricular theme in January 2023. Survey data from 100/134 (74.6%) study participants showed that most students agreed (somewhat agree/agree/strongly agree) the curricular theme was valuable (76.0%) and improved their understanding of the health impacts of climate change (80.0%). Most students agreed that their abilities in the five competencies improved because of exposure to the curricular theme. Qualitative comments indicated that students found the curriculum valuable, and also provided constructive feedback. Efforts to expand the curriculum to all four years of medical school and conduct further evaluation continue. Further scholarship is needed to present different curricular approaches and competency frameworks, which can ultimately support effective training of future physicians to understand and respond to the impacts of climate change on health and health equity.

Citation: Kline MC, Malits JR, Baker N, Shirley H, Grobman B, Callison WÉ, et al. (2024) Climate Change, Environment, and Health: The implementation and initial evaluation of a longitudinal, integrated curricular theme and novel competency framework at Harvard Medical School. PLOS Clim 3(5): e0000412. https://doi.org/10.1371/journal.pclm.0000412 Editor: Sherilee L. Harper, University of Alberta, CANADA Received: November 27, 2023; Accepted: April 8, 2024; Published: May 29, 2024 Copyright: © 2024 Kline et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: We have the raw data available in the submission and submitted as a supporting file. Funding: MK was supported by award number T32GM144273 from the National Institute of General Medical Sciences. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of General Medical Sciences or the National Institutes of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist.

Introduction Climate change is a present and escalating public health crisis. The World Health Organization (WHO) has described climate change as the single greatest health threat facing humanity [1]. The combined effects of climate change, air pollution, and ecological degradation have devastating consequences on human health, including severe weather events, extreme heat, poor air and water quality, altered crop yields and reduced food security, changes in vector ecology, and social conflict [2]. Critically, climate change, air pollution, and ecological degradation are issues of health equity that intersect with systemic forces such as structural racism, income inequality, and environmental injustice to exacerbate existing health inequities. For example, communities historically impacted by redlining experience greater health risks associated with increased exposure to oil and gas wells, higher levels of pollution, less residential tree cover and green space, and warmer surface temperatures in their neighborhoods [3]. The threat of climate change also has significant implications for the practice of medicine. To effectively care for patients, physicians must understand the ways in which climate change impacts health and be prepared to apply that knowledge through preventive care, diagnostic reasoning, and risk reduction counseling. Physicians’ role in the climate crisis is especially critical as they have been shown to be among the most trusted voices on climate action [4]. In recent years, there has been increasing awareness of the need for climate education in medical training and interdisciplinary health professions. There is a burgeoning literature documenting progress made in climate education across the medical, nursing, and public health fields, among others. For example, public health scholarship has formulated competency frameworks [5, 6]. In the field of nursing, thought leaders have described the challenges of integrating climate education [7], advocated for educational competencies [7] and provided recommendations for developing robust climate education for nursing students [7]. In undergraduate medical education, frameworks for educational concepts, competencies, and innovation in climate education have been described [8–10]. Internationally, institutional efforts to integrate climate education into medical school curricula have been reported [11, 12]. Large surveys have evaluated climate change and planetary health educational initiatives in medical schools globally, [13] and nationally, including the United Kingdom, [14] Australia, [11] and Ireland [15]. In Canada, national surveys were used to understand medical students’ experiences, attitudes, and interests in climate health education [16]. The importance of innovation in climate education in graduate medical education and post-residency fellowships has also been described [17–19]. These frameworks and curricular advances can further support students and practitioners’ career development in climate related advocacy, policy, research, and education, among other opportunities. Among U.S. medical schools, there is increasing recognition of the importance of undergraduate medical education in preparing future physicians to incorporate knowledge of climate change’s impacts on health into their clinical practice. A survey by the Association of American Medical Colleges (AAMC) showed that 55% of U.S. medical schools self-reported that the health effects of climate change was a required topic in pre-clerkship and clerkship courses in 2022, more than double the 27% of medical schools that reported such a requirement only two years prior [20]. Medical schools have begun to describe innovations in climate change curricula, which has been largely driven by medical students, but the field remains nascent [21–26]. Further dissemination of educational innovation reports may inspire medical school administrations to commit to developing climate curricular integrations that are appropriate to their specific context. Continued scholarship in this field is also essential to the development of broadly accepted competency frameworks that are endorsed by medical societies and accreditation bodies and can be readily applied by medical schools nationwide. To respond to this need, we describe an educational innovation at Harvard Medical School (HMS)—the development, implementation, and evaluation of the longitudinal, integrated HMS Climate Change, Environment, and Health curricular theme. We further describe the process of mapping the curriculum onto a newly developed competency framework.

Approach and methods Background Climate medical education was first developed at HMS by the Center for Health and the Global Environment, which was established in 1996. However, in the past decade, HMS offered only ad hoc climate content from a small group of faculty. In 2021, Students for Environmental Awareness in Medicine (SEAM), a medical student group at HMS, conducted an informal poll that found strong interest in climate medical education among their classmates. SEAM presented a proposal for a comprehensive climate curriculum to faculty leadership in August 2021, which was positively received. They subsequently led the development of a pilot lesson on the association between exposure to outdoor air pollution and the pathophysiology of asthma, which consisted of a pre-class preparatory video and assigned questions co-created by students and faculty. Students also secured a faculty mentor to oversee faculty efforts on curricular reform. To draw upon a wider range of expertise, the faculty mentor organized a climate health faculty working group (CHFWG). In August 2022, SEAM and the CHFWG began work with the goal of integrating climate content into every course in the first year of medical school training. With encouragement from the Dean of Medical Education, we began a collaborative process of curricular content development and also began seeking status as a formal curricular theme at HMS, which would help accelerate the development of a formal, required, and sustained curriculum. We received formal recognition as a HMS curricular theme in January 2023. The cohort described and evaluated in this manuscript received exposure to their final pre-clerkship climate curricular integration in September 2023. Content and pedagogy of longitudinal, integrated curriculum In the Spring of 2022, SEAM and CHFWG members began co-developing a longitudinal climate curriculum. The initial priority for our curriculum was to lay a strong conceptual foundation in the pre-clerkship phase of the Pathways curriculum track (HMS’s main track) and then subsequently expand climate education into the clerkship and post-clerkship phases and the Health Science and Technology (HST) curriculum track (a joint program with Massachusetts Institute of Technology). The pre-clerkship phase refers to the initial set of classroom-based courses taught in medical school—including anatomy, physiology, immunology, molecular biology, and social sciences—that precedes core clinical rotations. The clerkship phase refers to the collection of core clinical rotations—including internal medicine, pediatrics, surgery and obstetrics/gynecology—that are carried out in clinical settings, such as hospitals and ambulatory care centers. The final climate curriculum that was delivered in the 2022–2023 academic year is outlined in Table 1. PPT PowerPoint slide

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TIFF original image Download: Table 1. Description of course-specific Climate Change, Environment, and Health curricular (CCEH) theme integrations in the pre-clerkship curriculum. https://doi.org/10.1371/journal.pclm.0000412.t001 Our pedagogical approach intentionally focused on longitudinally integrating content into pre-existing course materials rather than developing an isolated, immersive course. The benefits of such pedagogy has been demonstrated in the literature [27]. The pedagogical principles of spacing and interleaving were used. Spacing is a teaching practice in which learning is distributed over time, rather than in a consolidated block [28]. Interleaving is a teaching practice that emphasizes the value of exposure to a variation of topics [29]. In an interleaving educational approach, learners engage with a specific topic, then leave that topic to learn new topics, and then return to the previous topic for further learning. Both spacing and interleaving practices encourage revisiting material with breaks in between. They were chosen because evidence has shown that they can enhance retention of information and increase capacity to create connections between concepts [29]. This integrated pedagogical approach also allowed for climate curriculum to be embedded without significant displacement of other educational topics, which was greatly valued by course directors. The format of curricular integrations varied widely and included lecture-based sessions, case-based learning, small group discussions, and clinic-based precepting exercises (Table 1). Moreover, climate content was designed to be relevant to the diverse professional interests of medical students and challenged students to develop an active practice of examining how climate change impacts their professional experiences and interests within medicine. In the 2022–2023 academic year, the pre-clerkship curriculum described the health impacts of climate change, air pollution, and ecological degradation on the following: vector borne disease, heat stress, mental health, food security, water scarcity, renal disease, allergic rhinitis, asthma, and coronary artery disease. Sessions also highlighted the role of physician advocacy on climate change policy and included a student-led small group discussion addressing hospital sustainability. Throughout the longitudinal curriculum, the intersections of climate change and global health equity, environmental justice, structural racism, and community partnership were emphasized, especially in relationship to Black, Indigenous and immigrant communities. Curricular design process SEAM and the CHFWG jointly approached course directors approximately six months prior to the start of each course, providing a rationale for climate medical education and presenting opportunities for climate curricular integrations. Workshop meetings were subsequently scheduled in which students presented ideas for climate integrations. CHFWG members provided climate and health expertise, and course directors offered insight on course priorities, including medical topics taught in the course and any relevant time constraints. These workshop meetings were structured intentionally with a spirit of co-creation among students and faculty with complementary knowledge bases and skill sets. The group explicitly discussed concerns they had about the impacts of climate change on the health of patients, which helped develop a sense of shared purpose and unified vision. Every course director that we solicited responded favorably to the outreach, resulting in new climate content integration into every course for which it was requested (Table 1). SEAM and CHFWG members also prepared a climate and health faculty development session for HMS faculty, organized by the office of the HMS Dean of Faculty Development. After the completion of each curricular integration, SEAM and the CHFWG solicited feedback from teaching faculty regarding their experience delivering the material and that of students receiving the material. Competency framework In parallel with curriculum design, the CHFWG and SEAM collaborated to develop a novel competency framework (Table 2). We began by conducting a landscape review of pertinent scholarship of climate education in U.S. medical schools [21–26]. After developing an initial framework, we used an adapted Delphi process to facilitate iterative feedback from stakeholders, including faculty, students, and the Dean of Medical Education. Our competency framework sought to reinforce the medical school’s existing medical education competencies. Our framework includes competencies addressing not only the impact of climate change on clinical practice, but also ones addressing how historical and structural factors exacerbate climate-related health inequities, how the healthcare system contributes to and is vulnerable to climate change, and how health professionals and institutions can contribute to climate solutions. Learning objectives were developed to accompany each competency. Once completed, the competency framework was used by faculty and students to map curricular integrations and develop new evaluation tools. PPT PowerPoint slide

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TIFF original image Download: Table 2. Description of the HMS Climate Change, Environment, and Health curricular theme competencies and learning objectives. https://doi.org/10.1371/journal.pclm.0000412.t002 Evaluation methodology A retrospective survey was administered in late August and early September 2023 after the final pre-clerkship climate- related curricular integration was presented to the first-year student cohort. While in the classroom, students were provided with a QR code that linked the survey questions. Participation in the survey was optional and the sole eligibility criteria was enrollment in the Pathways track. The HMS Program in the Medical Education’s Educational Scholarship Review Committee deemed this project to be quality improvement and therefore exempt from IRB review. We obtained students’ written informed consent to participate in the evaluation by placing the following statement prior to survey questions, “By participating in this survey, you consent to having your de-identified responses, analyzed solely in the aggregate, used in publications on this curriculum.” We used an eight-item survey to assess students’ perceived belief in the importance and value of the curriculum and their belief in how the curriculum impacted their development in the five curricular theme competencies. A seven-point Likert scale was used for responses to survey questions. Students were also provided with open text fields to comment on their perceived value of the curricular theme and share any additional thoughts. The data was accessed on September 2, 2023 for research purposes and authors did not have access to information that could identify individual participants during or after data collection. We analyzed the survey results for 100 of 134 (74.6%) eligible students who participated in the evaluation. We analyzed the descriptive statistics for all quantitative items (Table 3) using IBM SPSS Statistics for Windows, Version 28.0, Armonk, NY: IBM Corp. Responses to open-ended questions were reviewed for quality improvement. PPT PowerPoint slide

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TIFF original image Download: Table 3. Retrospective survey responses assessing importance, value and impact of the HMS Climate Change, Environment and Health curricular theme pre-clerkship content among HMS pre-clerkship students in Pathways track, Boston, MA, 2023 (n = 100). https://doi.org/10.1371/journal.pclm.0000412.t003

Outcomes and results Formal curricular theme status In 2022, the HMS curriculum formally recognized six curricular themes: Health Equity and Antiracism, Aging and End of Life, Sexual and Gender Minority Health, Substance Use and Pain, Trauma Informed Care, and Interprofessional Education. In January 2023, the HMS Educational Policy and Curriculum Committee approved a seventh curricular theme—Climate Change, Environment, and Health. This approval provided the curriculum with formal institutional status, and thereby created a mandate to integrate required content throughout all four years of the medical school curriculum. A new faculty theme director role was established with financial and administrative support from the HMS Office of Medical Education. Retrospective data We found that 94.1% of study participants agreed (defined here as somewhat agree, agree, or strongly agree) that understanding how climate change impacts human health should be part of all students’ medical education (Table 3). Furthermore, 76.0% agreed that the Climate Change, Environment, and Health curriculum theme was valuable, and 80.0% agreed the theme improved their understanding of the health impacts of climate change. We also found that most students agreed that their abilities in each of the five competencies had improved because of their exposure to the curricular theme. While the qualitative data collected do not meet standards for systematic analysis, there are several informative themes that emerged from review of open-ended comments. Broadly, these themes include a sense that the curricular integrations were: valuable and important to students’ learning in this domain (number of corresponding comments, N = 18); too simple in scope or would have benefited from further nuance (N = 4); not convincingly relevant to the health of Americans (N = 1); not adequately interactive (N = 2); and too limited/additional sessions would have been welcome (N = 3), especially on health equity topics (N = 2).

Discussion Students and faculty at HMS were successful in substantially increasing climate content in the pre-clerkship phase, creating a novel competency framework, and ultimately getting a formal institutional commitment for a longitudinal, integrated Climate Change, Environment, and Health curricular theme. Survey data showed that a substantial majority of students agreed that the curriculum was important and valuable, highlighting broad support for our efforts from students. Students largely agreed that the curriculum improved capacity in each of the defined competencies of our framework. However, survey data also showed that a portion (between 18.8% and 35%) of respondents only “somewhat agreed” with the prompts. Additionally, qualitative feedback provided suggestions for areas for improvement. Having formal theme status at HMS supported effective and synergistic collaboration between students, the CHFWG, course directors and deans in the Office of Medical Education. Student leadership catalyzed both the initiation and development of the curricular theme. Now, as a curriculum with institutional support, the curricular theme seeks to be student-inclusive but not student-dependent. Content expertise from the CHFWG facilitated the depth and breadth of curricular offerings. Significant buy-in and collaboration from course directors and deans provided critical formal institutional support. Furthermore, students and the CHFWG began the process of obtaining formal institutional commitment early on. Achieving recognition as a formal theme status was a critical step in accelerating the pace of curricular development in its first year. Areas to further strengthen the pre-clerkship curriculum include integrating lifespan approaches, organ-specific approaches, and more detailed teaching of health inequities faced by vulnerable populations. We also seek to increase climate-related skills through project-based learning in areas such as critical thinking, clinical assessment, and health advocacy. It will also be important to create more mentorship opportunities that help students interested in this work reflect on how they can incorporate it into their careers. Previous literature has highlighted the importance of these pedagogical approaches [5–9, 11, 12]. With an established first-year, pre-clerkship curriculum in place, further development is underway for the HST track curriculum and the clerkship and post-clerkship phases. Additionally, CHFWG is developing more structured opportunities for mentored projects and career development. We are collaborating with colleagues engaged in university-wide interdisciplinary climate curricular reform efforts across Harvard University. We have received institutional approval to conduct longitudinal surveys to evaluate future cohorts’ experiences of each component of the curriculum, which will allow us to better assess whether each curricular integration meets its objectives and will guide iterative refinement of the curriculum. The retrospective data presented in this manuscript has limitations in that it was a single cross-sectional survey assessment that was delivered at the end of a year of curricular integrations. As the survey was optional, not all students completed it, with a response rate of 74.6%. This response rate may have introduced bias, if those who did not fill out the survey were qualitatively different than those who did. A more detailed, longitudinal survey and a systematic process for qualitative data collection and analysis would be helpful to examining the strengths and weaknesses of each curricular integration. Given the early phase of curricular innovation in this area, additional scholarship is needed to present different curricular approaches and competency frameworks at all levels of undergraduate, graduate, and continuing climate medical education. Such scholarship may further the development of broadly accepted competency models that can be utilized by medical schools and accreditation bodies. Our work in developing a competency-based, longitudinal, integrated curricular theme is relevant not only for physician training, but for interdisciplinary health professions, many of which are working to significantly expand climate education in their respective fields. Greater implementation of climate medical education and standardization of competencies may help to more effectively train future physicians to understand and respond to the impacts of climate change on health and health equity.

Acknowledgments The authors wish to thank Dr. Edward M. Hundert, Dr. Bernard Chang, and the Office of Medical Education at Harvard Medical School for their support of this initiative.

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