JAMA Forum: Climate Change and Training the Next Generation of Physicians

More than a century after the Flexner Report laid the groundwork for standards of medical education in the United States, much has changed about how we train physicians. Certain key principles, like the need to train physicians in the scientific methods, remain a bedrock. However, since Flexner, the nature of how we create and consume knowledge—and how we translate it into clinical care—has been transformed.

It is no longer possible for physicians to retain all the key knowledge about clinical care in their heads—and luckily, with the advent of technology, they no longer have to. The rapid updating of medical knowledge with new scientific studies means that much of what I was taught in medical school in the 1990s is no longer valid today. Thus, the primary purpose of medical education cannot be about teaching facts alone. Instead, it should be about teaching students to think scientifically, to solve problems, and to understand the broader phenomena that shape disease and clinical practice.

It is in this context that a recent piece in the Wall Street Journal, while well-intentioned, was off base. In his commentary, Stanley Goldfarb, MD, former associate dean of curriculum at the University of Pennsylvania’s Perelman School of Medicine, argues that the increasing focus in medical education on social factors that influence health detracts from scientific and clinical education. The piece set off a firestorm, but a key premise of this piece—that patients want a caring, competent clinician above all else—is right. Unfortunately, Goldfarb’s examples of topics best left aside reflect a fundamental misunderstanding of what is needed to produce effective physicians. One such topic, essential to training the next generation of effective clinicians, is climate change.

How Climate Changes Health
A fundamental principle of clinical medicine is that the environment around us shapes the environment within us. Climate change is rapidly shaping the environment around us, through rising temperatures, severe weather events, and access to and quality of drinking water, among other phenomena. These environmental changes affect respiratory disease, cardiovascular disease, cerebrovascular mortality, vector-borne illness, and mental health, to name just a few. Beyond its population health effects, an understanding of how climate change affects disease is essential for effective clinical decision making.

Take, for example, Lyme disease. The Centers for Disease Control and Prevention reports a doubling in tick-borne illness during 2004 to 2016, with Lyme disease comprising more than 80% of cases. The geographic spread of the disease has increased substantially, due in part to climate change, as warmer temperatures change habitat suitability for ticks that carry the disease. What does this mean for practicing physicians? For those working in areas that historically had no substantial Lyme disease, failing to consider the infection in a patient with associated symptoms would lead to a misdiagnosis. Without an awareness of how climate change is affecting the geographic distribution of vector-borne illness, physicians will be far less effective at diagnosing diseases that are changing in their distribution and frequency.

Another example involves side effects of drugs. Certain medications, such as antipsychotics and diuretics, cause an increased risk of complications in the setting of severe heat. For example, taking a combination of an angiotensin-converting enzyme (ACE) inhibitor and a diuretic triples a patient’s risk of hospital admission for heat-related illness—an interaction that physicians living in areas that historically have not experienced extreme heat may not have had to worry about when prescribing the combination. However, as climate change causes more heat waves and higher average temperatures, physicians who neglect to consider the interaction between certain medications and heat could harm their patients. In contrast, a clinician who is familiar with how climate change is affecting the temperatures in their region could prescribe a safer alternative or educate patients on the risk and steps they can take to mitigate these effects.

The manifestations of climate change are likely to shift over time, and we cannot teach medical students how to be effective clinicians in the future without teaching them about how climate affects health. Their medical education will need to still be useful decades from now, and although continuing medical education can help fill knowledge gaps, medical school is where students acquire foundational knowledge and learn frameworks that will hold them for the rest of their careers. To predict the health problems that their patients will face years down the road, medical students need to understand fundamental, underlying trends. Climate change is one such trend.

Challenges for Health Care Delivery
Climate change also poses threats to health care delivery itself. With rising frequency and intensity of severe weather events, we can expect to see more of the kind of damage caused by Hurricane Harvey and Superstorm Sandy. In these types of circumstances, hospitals and clinics may be physically damaged or face power outages. Roads may be flooded or destroyed, making it hard for emergency services to reach patients or for patients to come to physicians. Severe weather events anywhere around the globe can disrupt supply chains in the United States, as we saw when Hurricane Maria in Puerto Rico caused shortages of intravenous fluids in the United States for months.

Future physicians, especially those in the most vulnerable areas of the United States, need to be prepared to treat patients under these types of circumstances. This relies on effective problem solving from an organizational leadership standpoint—ensuring that preparedness plans are in place—as well as from the standpoint of individual clinicians, who must adapt care provision to the available resources. Medical schools need to prepare future clinicians to understand these threats, predict their consequences, and respond effectively to them.

Preparing Physicians for the Future
Although the majority of US adults agree with the scientific consensus that human-caused climate change is occurring, a small group of antiscience individuals have made climate change a political issue. In that way, climate change is akin to vaccines—a loud minority of people who doubt the scientific consensus has raised questions about vaccine efficacy and safety.

Medical schools must not let issues politicized by antiscience individuals cause them to shy away from teaching about climate change or vaccines, or other politicized topics that affect patient health, such as reproductive health or treatment of substance use disorders. The guidepost should not be whether something is political, but whether it is fundamental to the provision of high-quality care. And given the overwhelming scientific consensus that climate change is already affecting clinical practice and will continue to do so in the future, it would be educational malpractice to neglect teaching the health effects of climate change.

A century ago, at the time of Flexner, it might have been possible to relay the entire body of scientific medical knowledge in 4 years of medical school. Today, that is not possible or even desirable. The purpose of medical school is to teach students to recognize the forces shaping health and health care and to understand the factors that will change disease manifestation, disease presentation, and clinical care. This means understanding the broader trends of the world around us.

With the ubiquitous presence of information technology, including clinical decision support tools, students and physicians now have ready access to all the medical knowledge ever created. This has not yet translated into a transformation of medical education; many medical schools still spend too much time teaching topics such as laboratory methods and having students memorize anatomic details that can be covered more quickly or not at all. Although there will always be tradeoffs when new material is added, shifting a few hours or even a few days of curricula even from important topics that are fact based (and largely accessible in electronic form) to focus on larger trends would be more beneficial in the long run.

Climate change is our reality. It is going to change the way we provide clinical care. For that reason, it needs to be taught in every medical school across the nation. Shying away from controversial issues will not serve future generations of physicians or their patients well. An understanding of climate change is beneficial to clinical practice today—and will be essential to effective clinical practice tomorrow.

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About the author: Ashish K. Jha, MD, MPH, is K. T. Li Professor of Global Health and Health Policy at the Harvard T. H. Chan School of Public Health and a practicing internist at the Veterans Affairs Boston Healthcare System. He received his doctor of medicine from Harvard Medical School and was trained in internal medicine at the University of California, San Francisco. He received his master’s in public health from Harvard School of Public Health. Dr Jha’s major research interests lie in improving the quality and costs of health care. His work has focused on 4 primary areas—public reporting, pay for performance, health information technology, and leadership—and the roles they play in fixing the US health care system. (Image: Aubrey LaMedica/Harvard T.H. Chan School of Public Health)

 

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.



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