In September 2017, Hurricane Maria battered the islands of the Caribbean, devastating, among other territories, the island of Puerto Rico—my birthplace and home. I was a medical student on the island at the time, starting my clinical years, and could not have imagined the rude introduction into patient care I was about to receive. To make a long story short: all of us on the island worked tirelessly for months to mitigate the damages caused by the hurricane, but a return to baseline has not been achieved, even to this day. Damage to infrastructure was ubiquitous and the loss of life immeasurable. Storms similar in magnitude to Hurricane Maria are projected to increase in frequency over the coming century, a trend driven at least in part by anthropogenic climate change. This effect on tropical cyclones is just one of myriad anticipated consequences of the warming of our planet.1 Given that the populations we care for as specialists (and trainees) in Internal Medicine will very likely be affected, it seems prudent to reflect on our particular skillset to find the ways in which we are best equipped to tackle this issue. Education is a significant part of what we do as internists, and it has been used as a tool to fight some of the medical community’s most formidable battles. In the search for suitable strategies in our battle against climate change, the mobilization of the internist-educator seems like a sensible way to start.
Unfortunately, there is a deficiency in medical education pertaining to the effects of climate change. Although some medical schools made efforts to integrate the concept of climate change into their curricula, and there is a defined interest on behalf of the health professional community to enhance education on the topic,2,3,4 there still remains much to be done. Academic internists are thus in the position to contribute to the development of a relatively new branch of medical pedagogy. One important point to be recognized is that our work as internists imparts deep understanding of the nuanced relationship between clinical pathology and a patient’s environment. We can draw on this understanding to develop practical and realistic educational curricula for medical trainees.
At our institution, we are developing case-based discussions that integrate aspects of the physical science of climate change, the geopolitical considerations to be taken into account (e.g., forced migration) and the mechanisms by which disease can be brought on or exacerbated. One case, for example, highlights the intricacies of caring for a displaced population of Puerto Rican veterans. Issues pertaining to access and continuity of care, cultural and language barriers, and mental health consequences of traumatic events are woven into a discussion of principles spanning from basic science to advanced pathophysiology. These discussions take place as part of a larger case-based learning curriculum that consists of almost-weekly sessions during academic half-days. The sessions are held with participation of a variety of learners, ranging from undergraduate nursing students, to psychology and social work interns, to medical residents. This is done with the intention of exposing participants to the entire gamut of the healthcare team, in order to better understand how multidisciplinary collaboration can lead to higher-quality care. Given the opportunity for residents to contribute to this curriculum, the introduction of climate change themes is my ongoing project in our program. With the increasing use of case-based learning in medical education, similar endeavors could be readily undertaken at other academic institutions.
A recent survey showed that patients seem to trust their physicians when it comes to environmental issues. A potential challenge to making the most of this trust is the additional finding that many physicians are unsure about their role in addressing this problem and may feel uncomfortable in doing so.5 Although confidence when speaking on the topic is expected to grow with the increasing education on it during medical training, it is important to address the lack of clarity on our role. As physicians, we are fundamentally involved in the promotion and maintenance of health. It is most definitely our responsibility to disseminate accurate information on climate change because it is pertinent to our patients’ health. Just as we would be alert to factors that would preclude adequate glycemic or blood pressure control, we can, for example, counsel patients about the effects of changing air quality on allergies, asthma, and other chronic pulmonary diseases. It could be so valuable to incorporate climate education into patient encounters and raise patients’ awareness of climate change and the possible consequences on their lives. A brief discussion regarding available resources for monitoring and preparation could go a long way in reducing risk of exacerbations and adverse events.
Hurricane Maria and the following weeks were instrumental in my decision to become an internist and sparked my interest in climate change and its consequences. Unfortunately, anthropogenic climate change has already put into motion its colossal wheels, and efforts made now to halt its progression have come relatively late. While society should continue to advocate for measures to quell the impact of carbon emissions on our atmosphere, there must be an increased focus on strategies to adapt to it. We, as internists, will undoubtedly play a tremendous role in this adaptation process and our strongest tool to do so lies perhaps in education.
I urge fellow internists and trainees to make deliberate efforts at their own institutions to continue the adoption of pedagogically sound methods to integrate climate education into our training. The result will be a generation of physicians who will, in turn, easily grasp the links between the environmental science, social determinants of health, and disease overall. We should also keep in mind that efforts made to educate our patients may yield downstream benefits in the form of more efficacious healthcare utilization and increased societal awareness of this problem. More than anything else, it will provide an opportunity to improve the quality of care we provide—as internists, we should want nothing more.
- Pachauri RK, Allen M, Barros V, et al. Climate change 2014: Synthesis report. Contribution of working groups I, II and III to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change. Geneva, Switzerland: IPCC; 2014.
- Wellbery C, Sheffield P, Timmireddy K, et al. It’s time for medical schools to introduce climate change into their curricula. Acad Med. 2018;93(12):1774-1777. doi:10.1097/ACM.0000000000002368.
- Rabin BM, Laney EB, Philipsborn RP. The unique role of medical students in catalyzing climate change education. J Med Educ Curric Dev. 2020;7:2382120520957653. Published 2020 Oct 14. doi:10.1177/2382120520957653.
- Maxwell J, Blashki G. Teaching about climate change in medical education: An opportunity. J Public Health Res. 2016;5(1):673. Published 2016 Apr 26. doi:10.4081/jphr.2016.673.
- Boland TM, Temte JL. Family medicine patient and physician attitudes toward climate change and health in Wisconsin. Wilderness Environ Med. 2019;30(4):386-393. doi:10.1016/j.wem.2019.08.005.
Advocacy, Health Equity, Medical Education, SGIM, Social Determinants of Health
Dr. Cuvillier Padilla (firstname.lastname@example.org) is a second-year Internal Medicine resident in the VA Center of Outpatient Education (COE) track at the Cleveland Clinic in Cleveland, OH. Dr. McNamara (email@example.com) is a professor of medicine at Case Western Reserve University School of Medicine and director of the Center of Outpatient Education at the VA Northeast Ohio Healthcare System.
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