Are we teaching the health impacts of climate change in a clinically relevant way? A systematic narrative review of biomechanism-focused climate change learning outcomes in medical curricula

Abstract

Purpose

Introducing biomedical approaches to the health impacts of climate change can improve medical student engagement with relevant climate-related issues, improve the development of medical schemas, and minimise displacement into crowded medical curricula. This paper aims to systematically review the medical education curricula related to climate change, with a particular focus on systems-based biomechanisms for the health impacts of climate change. We do this to provide a clear agenda for further development of learning outcomes (LOs) in this area to maximize the clinical applicability of this knowledge.

Material and Methods

A systematic review was undertaken following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA; Liberati et al. 2009) guidelines for both the published and grey literature. Five databases (PubMed, SCOPUS, ERIC, Open Access Thesis and Dissertation, and Proquest Global Dissertation and Theses) were searched for works published between 2011 and June 2023. Full texts that contained LOs were the main inclusion criteria for the final review. Descriptive and content extraction guided the final narrative synthesis.

Results

Analysis indicated that biomechanism-related LOs represented about 25% of each published LO set, on average. These outcomes were primarily at the “understand” level of Bloom’s taxonomy and were spread across a range of body systems and climate-change aspects. Infectious diseases and extreme heat were strong focuses. Authorship analysis indicated that the majority of these sets of published LOs are from Western contexts and authored by researchers and educators with medical and population health qualifications.

Conclusions

Biomechanism-focused teaching about the health impacts of climate change is relatively rare in published curricula. Of the available sets of LOs, the majority are sourced from Western authors and are focused on a fairly circumscribed set of biomedical topics. There is scope to both broaden and deepen curriculum in this area, and we would recommend the field prioritise collaboration with medical educators from the Global South, where the effects of climate change are already the most acutely felt.

Keywords:

• Climate change
• medical education
• medical students
• learning outcomes

Introduction

There is now no doubt that climate change has impacts on health (Rocque et al. 2021; Watts et al. 2021) and that the doctors of tomorrow will need to be equipped to address these impacts (Philipsborn et al. 2021). To date, the strongest voices in this area of medical education have been students themselves (Rabin et al. 2020) and researchers with a Population Health focus (Maibach et al. 2010). As a result, the health impacts of climate change (HICC) are often framed in the medical education literature as “updating the environmental determinants of health” (Horton 2018). However, for the majority of medical graduates, medicine is not practiced at a population level. The clinicians of tomorrow will be addressing concrete biomedical issues, possibly in a narrow, specialised field directly related to negative health outcomes caused by climate change.

Practice points

• The ways in which HICC content is included in medical education curricula emphasises “environmental determinants of health,” and biomechanism-related content is an area for development;

• A systematic narrative review of published HICC-related learning outcomes (LOs) yielded a topic-coverage heatmap that can be used to guide the future development of LOs and be applied immediately in the development of curricula.

• Results indicated that biomechanism-related content was relatively rare (∼25%) and covered a limited range of the existing biomechanism evidence.

A clinician clearly benefits from an understanding of the public health impacts of extreme climate events. The teaching and learning on environmental determinants of health is invaluable to a future clinician. For example, when facing an extreme heat event, they must know who is most vulnerable—people with limited access to resources, older adults, and those with underlying health conditions. However, at a practical, individual (i.e. patient) level, it is also imperative that medical graduates understand how integrative systems physiology is affected by the impacts of climate change and how to advise patients to prepare for these events. For example, in an extreme heat event, the doctor should be able to advise their patient who has congestive heart failure that heat stress places greater demand on the cardiovascular system because the blood is redirected from the central system to the periphery to dissipate heat from the body. They may have a reduced plasma volume because of sweat loss and dehydration. They should also be able to offer solutions for mitigating risk during the heat, specifically to remain in a cool place or use effective cooling strategies (Jay et al. 2021) if air conditioning is not accessible, prescribe an appropriate amount of water to drink (catered to their medicines) and ensure they limit long periods of physical activity (especially in the heat). Without specific, biomechanism-focused teaching of content such as this, the medical graduate is ill-prepared for future practice.

Educationally, we also know that retention of basic sciences content is positively correlated with perceived clinical relevance (Malau-Aduli et al. 2019) and that integrating basic science with its clinical relevance is a way of transitioning from passive to active learning in medical education (Adam et al. 2017). The need for climate change clinical medical education that foregrounds the clinically relevant, patient-level biomechanisms of the health impacts is clear. There is also a substantial push amongst physiologists (Jay 2022) to include actual physiological-based evidence in policy and education where appropriate. Horton (2018) proposes that associating climate change with biomedical mechanisms assists in medical education by aligning with the traditional focus of preclinical medical curricula, physiology, pathology, and pharmacology. This alignment would improve the integration of HICC into current medical curricula rather than displacing existing content; solidify already existing schemas and reinforce medical students’ learning; expand the potential for biomedical research in a climate change context; improve patient education (Lannigan 2004) and overall enhance student engagement with the current climate crisis.

To date, no consensus curriculum has been developed despite the important work already done in this area. For example, Burch et al. (2021) explicitly focused on the biomedical curricula and developed a “planetary health-organ system” map with the aid of several clinicians. However, the practical reality of how to incorporate this type of teaching about HICC in medical education is less clear. There is also a wide range of heterogenous, opt-in, extra-curricular sets of resources (Majra and Acharya 2009; ACP 2016; Petrin-Desrosiers et al. 2016; Perrotta 2019; GCCHE 2020; Fadadu et al. 2021), including some produced by professional Medical Associations (Australian Medical Association 2015; Perrotta 2019). The current study reviews these and the available published medical education curricula addressing the HICC with a view to establishing: 1) which biomechanism-related topics are taught and 2) who is contributing to this conversation and whether that participation has shaped the content.

To our knowledge, there is no published systematic literature review specifically examining the inclusion of biomedical mechanisms of the HICC in medical education and their primary LOs. There is a systematic scoping review protocol for teaching HICC (results are not published; Osama et al. 2018) and a systematic literature review investigating teaching doctors about ecosystems (where the HICC is not a focus; Walpole et al. 2016). The current paper will provide the first systematic evidence looking at biomechanisms in HICC LOs. The review will allow us to understand the degree to which the published curricula focus on systems-based biomedicine and physiology, rather than focusing on the “environmental determinants” of health. We will also be able to consider the participation patterns in this literature, including the proportion of this work completed by authors qualified in population or public health and the ways this representation is associated with any patterning of the content. We are also interested, in an exploratory manner, in considering the degree of representation from Western, Educated, Industrialised, Rich, and Democratic (“WEIRD”; Henrich et al. 2010) countries and the extent to which the national representation is related to the types of climate change impacts that are in focus.

Methods

Design

A systematic literature search was conducted, following a systematic protocol that allows us to report following the PRISMA guidelines. The search is outlined in five sections according to Cook and West (2012) and following tips from Sullivan (2018). A narrative synthesis of the findings followed the standard set by Popay et al. (2006). The protocol for the review is on OSF (https://osf.io/cb3zk/?view_only=9c20ffa618bf4b8ca3ec8c1f2c459820).

Focused research question

The core focused research question was: what is the distribution of content and focus of the “Health Impacts of Climate change” concepts taught in published medical education curricula? Subquestions focused on a) biomechanism coverage (what is covered) and b) the context from which the curriculum is drawn and the theoretical perspectives of the lead authors (by whom).

Search strategy

MeSH and keywords are in Table 1. The different disciplines within medicine were drawn from the Oxford Medicine Online Handbook (Oxford Academic 2023). It was necessary to detail the name of each discipline, rather than using only the umbrella term “medic*,” as our specific focus was systems-related biomechanism teaching. The search term was submitted to scholarly databases PubMed, SCOPUS, and ERIC, and grey literature databases Open Access Thesis and Dissertation (OATD) and Proquest Global Dissertation and Theses. The search term was submitted to these five databases on the 9th of April 2021. Citations of articles were downloaded and imported into EndNote X9. The search was then updated using the same query in the same databases in June 2023.

Table 1. PIO Framework for search term building “and” operator connected the three components.

Component of review topic	MeSH and/or keyword search terms
Population	(clinic* OR medic* OR anaesthetic* OR allergy OR “Cardiovascular Medicine” OR “Cardiology” OR genetics OR neurophysiology OR pharmacology OR therapeutics OR dermatology OR endocrinology OR diabetes OR gastroenterology OR genito-urinary OR geriatric* OR “Infectious Disease*” OR oncology OR toxicology OR neurology OR “Pain Medicine” OR palliative OR “Rehabilitation Medicine” OR nephrology OR respiratory OR pulmonology OR rheumatology OR “Sleep Medicine” OR “Sports Medicine” OR “exercise medicine” OR “Critical Care” OR “Emergency Medicine” OR “Forensic Medicine” OR haematology OR gynaecology OR obstetrics OR “Occupational Medicine” OR ophthalmology OR otolaryngology OR “ENT” OR paediatrics OR neonatology OR pathology OR immunology OR microbiology OR virology OR pharmacology OR “Complementary Medicine” OR “Alternative Medicine” OR “Primary Care” OR psychiatry OR “Addiction Medicine” OR “Learning Disabilities” OR “Public Health” OR epidemiology OR radiology OR oncology OR “Nuclear Medicine” OR “Reproductive Medicine” OR surgery OR “Peri-Operative” OR orthopaed* OR surgery OR urology
Intervention	“Climate change” OR “extreme weather”
Outcome	Teach* OR education OR undergraduate OR post-graduate OR curricul*

Inclusion criteria

Studies were eligible for inclusion if they were published in English and published after 2011. This earliest date limitation was imposed, as this was the date after which the evidence base on the HICC was firmly established. After 2012, there was a substantial uptick in both the biomedical evidence and the systematic reviews summarising that evidence in an accessible way for educators.

Articles need to be peer-reviewed or be scholarly works (e.g. PhD thesis) or a report published by a professional body association (e.g. The International Federation of Medical Students Association). Articles needed to present LOs for inclusion in final eligibility. Articles were excluded if related to nonmedical healthcare disciplines (e.g. nursing, public health sciences), or about general sustainability initiatives unrelated to the HICC.

Articles were selected for inclusion in two broad stages: first, identifying and selecting articles, and second, appraising and synthesising the literature. Stage one was performed through a two-step process: in step one, the first and second authors independently screened titles from imported hits. Titles that were not clearly included or excluded were triangulated by the third author, who confirmed final hits for abstract review. In step two, abstract screening was then performed independently by the first and second authors. Abstracts that were not clearly included or excluded were discussed and negotiated between the first two authors.

Data extraction

Table 2 describes the descriptive and content data extracted from eligible papers. Data was extracted into Microsoft Excel 2013. Descriptive analysis included article type, author(s), department, countries of published work, and authors’ qualifications. The content analysis focused primarily on the papers’ proposed or sample curricula on climate change integrating into medical training, including medical school and junior doctor training programs after medical school. Domains or broader themes that were proposed were listed; sub-domains that detailed the HICC were identified and examined according to their association with biomedical concepts.

Table 2. Data extraction variables.

	Item type	Description
Descriptive analysis	Reference detail	Authors
	Paper type	Commentary paper, original research, perspective article
	Country/countries	Of all authors in paper. Excludes National Medical Student Associations*
	Year published
	Author qualifications	Named degrees
	Author departments	E.g. Paediatric, neurology, Global Health departments
Content analysis	Names of domains and relevant sub-domains	Sub-domains considered relevant if includes HICC in biomechanism context
	Number of learning outcomes in HICC
	Learning outcomes related to the HICC	If more general LOs, then whether LOs recognise HICC for different specialties
	Key biomedical discipline terms	Whether LOs had mentions of medical specialties (e.g. cardiology, respiratory) and if so, details of Los
	Climate change phenomena identified	E.g. Extreme weather events (heatwaves, storms, droughts) or meteorological events (rising temperatures and humidity)

Biomedical topics were defined according to First Aid USMLE Step 1 (Le et al. 2019), a standardised preclinical textbook focusing on biomechanisms. Climate change phenomena identified (both with and without relation to the HICC) in the LOs were extracted.

Analysis

Both descriptive and content data were analysed on Microsoft Excel 2013. Analyses were completed in two phases. The first addressed the question of “what is being covered” in published LOs on HICC. This analysis included collation of the level of training, content domains proposed, source, number and type of LOs (conceptual vs technical), and proportions of LOs associated with biomechanisms. The LOs were qualitatively analysed by two authors, using a content analysis (Hsieh and Shannon 2005) approach, to identify the main themes that were in the total corpus of LOs. Papers were further coded for the sub-disciplines, biomedical focuses, and climate-change topics addressed by the LOs.

The LOs were also coded for core tasks using Bloom’s taxonomy-type approach. Analysis was done using an automated count function that identified 68 unique tasks in the dataset (e.g. “recognise,” “evaluate,” etc.) and then counted the presence of these tasks in the stated LOs. As a result of a number of the LOs in the set being double-barrelled (i.e. including two or more of these tasks), there is an inflated total count. In an effort to gain an understanding of the full picture of the tasks involved, all counts were retained.

The next phase of analysis addressed the question of “by whom”—collating information on who was contributing to these published sets of LOs in terms of location of work, qualifications of authors, and some qualitative analysis of the focus of each set of Los.

Results

PRISMA flowcharts outlining the identification, screening, eligibility, and inclusion of relevant articles are in Figure 1 (original search; 2021) and Figure 2 (updated search; 2023). NB: one paper was withdrawn and republished in amended form in the time between searches, so is represented in both searches. Overall, a total of 4639 articles were identified through five academic and grey literature databases. Duplicates were removed in EndNote X9. One hundred and seven articles were sought for full-text retrieval, and 20 had LOs for inclusion in the final study. The reference lists of the 107 full-text articles were screened, and six further websites and organisations were included in the screening process. The first author reviewed these documents: three did not provide LOs, and one had the same curriculum as another resource in the identified document. A total of 22 (Thompson et al. 2014; Maxwell and Blashki 2016; Valois et al. 2016; Walpole et al. 2016; Teherani et al. 2017; Canadian Federation of Medical Students (CFMS) Health and Environment Adaptive Response Taskforce (HEART) 2019; GCCHE 2020; InciSioN UK Collaborative 2020; Rabin et al. 2020; Goldman et al. 2021; Gomez et al. 2021; Kligler et al. 2021; Kuczmarski et al. 2021; Philipsborn et al. 2021; Dunne et al. 2022; Madden et al. 2022; Navarrete-Welton et al. 2022; Wabnitz et al. 2022; Aasheim et al. 2023; Bevan et al. 2023; Blom et al. 2023; Hatfield et al. 2023) documents with sets of LOs (20 peer-reviewed published papers and 2 online resources) were included in the final analysis.

Figure 1. Prisma flowchart outlining study screening process.

Figure 2. PRISMA flowchart outlining process for updated search, June 2023.

What is being covered?

We identified 536 LOs across the 22 documents. Content analysis indicated that the LOs are apportioned across four key themes and one sub-theme, often made explicit by author-categorisations in the original papers. The themes and sub-theme are as follows:

1. knowledge of health, environment, and their relationship;

2. impacts of climate change on epidemiology, health risks, and presentations;

3. impacts of climate change on health systems and delivery; and,

4. adaptations and changes to clinical practice in response to climate change.

   1. values, leadership, and advocacy around climate change awareness and mitigation

These themes span the core components of the doctor’s role, and biomechanism-related content was woven across almost all of these topics.

Analysis of the core task (Bloom’s taxonomy) data indicated that the majority of outcomes (47%) included tasks at the “understand” level (e.g. “describe,” “discuss,” and “explain”). Another 30% were at the “apply” level (e.g. “demonstrate” and “use”), 10% at the “analyse” level, and 5% at the basic “remember” level. Few were at the evaluate (2%) or create (4%) higher-order level of the taxonomy.

The total number of LOs per paper and the proportion of LOs with a biomechanism focus are summarised in Table 3. The majority of LOs were at the training level of medical students, with only two exceptions at the level of professional training. The proportion-per-set of LOs focused on biomechanisms ranged from 0% up to 82% (see Table 3). LOs that included a biomechanism focus averaged approximately a quarter of the published LOs per paper.

Table 3. Learning outcome count and proportion focused on biomechanisms.

First author	Total learning outcomes	Proportion of LOs related to biomechanisms
Thompson (2014)	13	.08
Maxwell (2016)	18	.17
Valois (2016)	24	.33
Walpole (2016)	18	.22
Teherani (2017)	15	.13
CFMS (2019)	71	.35
Incision UK (2020)	60	.08
GCCHE (2020)	47	.13
Rabin (2020)	49	.55
Goldman (2021)	15	.33
Gomez (2021)	5	.20
Kligler (2021)	15	.73
Kuczmarski(2021)	35	.57
Philipsborn (2021)	24	.50
Madden (2022)	31	.06
Navarette-Welton (2022)	11	.82
Wabnitz (2022)	31	.03
Dunne (2022)	8	.00
Aasheim (2023)	14	.00
Bevan (2023)	16	.13
Blom (2023)	9	.22
Hatfield (2023)	7	.29

Of the biomechanism-focused LOs, a range of specific topics and domains were represented. The most common topics in the biomedical LOs were Infectious Diseases, Psychiatry and Psychology, Respiratory, and Cardiology. Further, LOs in Pharmacology, Nutrition, Reproduction, Renal, Endocrine, Musculoskeletal, Dermatology, Gastrointestinal, and Neurology topics were included. Hematology-focused LOs related to HICC were not identified in the literature. Oncology was mentioned only in the context of respiratory LOs (lung cancer) and skin systems. Heat-related illnesses were mentioned in nine of the 21 articles.

Following an analysis for verbatim duplicates and a three-author screening process to identify in-spirit duplicates, 144 unique biomechanism-related LOs were identified and coded for climate change and biomedical topics. A heatmap summarising the coverage of these two topic dimensions is in Supplementary Appendix A. A review of Bloom’s taxonomy-type tasks for this subset of LOs yielded a similar pattern to that of the whole set: a marked majority (70%) were at the “know” and “understand” levels, with a smaller portion (22%) at the “apply” level and the remainder spread across the remaining four levels.

By whom?

There were 150 unique authors represented by the 22 papers analysed. The United States dominated the research with 35% of authorship, followed by the UK (26%), Canada (14%), and Australia (5%). Only 20% of authors were working in the rest of the world, including Denmark, Brazil, South Africa, France, Columbia, Tunisia, Panama, Egypt, The Netherlands, Norway, Portugal, and Ecuador.

About half of the authors (n = 74) had qualifications that were easily accessible (either listed in the article or their university research profile), and the overwhelming majority of those authors (72%) had either medical qualifications or were studying for medical qualifications. There were also a number of population-health-oriented qualifications (18%), education qualifications (8%), and PhDs in biomedical fields (10%) or postgraduate degrees in “environmental health” (5%). Please note that a number of authors had several qualifications each, so these figures will not sum to the total. Author departments ranged from paediatrics, anaesthetics, global health, and science education.

Discussion

This paper is the first systematic literature review of climate change curricula in medical education, with a specific focus on the inclusion of biomechanisms in LOs related to the HICC. We sought to review published LOs and curricula for medical education on the HICC to understand the coverage of biomechanism topics, as well as the voices contributing to the discussion in this space. This question is important, as it speaks to the relationship of the LOs to clinical practice for a graduate working with individual patients.

Key findings

First, the coverage of the existing LOs on HICC was spread across four broad topics identified in our analysis of the LOs: knowledge of the relationship between environment and health, the impacts of climate change on epidemiology, health risks, and presentations; the impacts of climate change on health systems; and adaptations and changes to clinical practice in response to climate change. There was also a fifth recurring topic that was not always present but was a strong focus in several sets of LOs and has been treated as a sub-topic: that of values and advocacy around climate change awareness and mitigation. The themes identified by the current authors are drawn from a combination of our own thematic interpretation and the domains or headings used by the original authors. These recurring themes offer some hope in the ways they link to models of the knowledge systems involved in quality improvement. Batalden and Davidoff’s (2007) model of quality improvement, for example, characterises the knowledge systems required as 1) generalisable scientific evidence (covered in the knowledge and epidemiology themes); 2) particular contextual awareness; 3) extant performance measurement (both covered in the themes on impacts to health systems and clinical practice); and 4) plans for change (covered in the clinical practice LOs, as well as the values and advocacy sub-theme). All that remains in this particular model of quality improvement is to develop knowledge systems for the execution of the planned changes as the current students move into clinical practice.

The LOs analysed, both from the broad HICC set and the biomechanism-focused subset, were overwhelmingly set at the “Understand” level of Bloom’s taxonomy. This type of categorising of LOs is not just an exercise for the purposes of determining the best type of assessment to measure the achievement of the LO. Using this taxonomy also allows us to “determine[e] for a particular course or curriculum the specific meaning of broad educational goals” (Krathwohl 2002). In the context of our analysis, this affords a view of the aims of these published curricula: to allow medical students to understand and apply knowledge about the HICC in their clinical practice. In many ways, it is fitting for new content based on an emerging evidence base to be largely pitched at the “understand” and “apply” level (rather than at a higher-order level) in medical education. The taxonomy is hierarchical for a reason: before a medical student can evaluate, create, analyse, or apply their knowledge of HICC, they must first understand it. However, medicine is an applied discipline, and only 30% of the HICC LOs are pitched to teach the medical student to apply their knowledge. Application is critical for medical education and our analysis suggests that the next generation of doctors may continue to be under-skilled, albeit better informed.

Focusing more specifically on the biomechanism-related LOs, our analysis indicated that these were a small proportion of the published LOs and averaged about 1 in 4. The majority of the LOs were related to “environmental determinants of health,” and the focus was at the population level, on health systems, or on social and ethical issues. We do not posit this as a problem so much as a snapshot of the state of the art. These larger social, system, ethics, and advocacy issues are incredibly valuable to medical graduates. They are not, however, the full picture. The bread and butter of a practicing doctor is about applying biomedical knowledge to clinical problem solving, and the key knowledge around the biomechanisms of HICC was under-represented. Of the LOs that were related to biomechanisms, the strong focus was on infectious diseases (including vector-borne, water-borne, and zoonotic diseases), followed by health impacts relating to air quality and extreme heat.

We collated here a list of the 144 unique biomechanism-focused LOs identified in the review, yet the gaps are more notable than the coverage. For example, across 22 papers with 536 HICC LOs, hematology was not identified as the topic of any of the LOs published. This undervalues its importance in the climate change curricula, as crop failures are more likely to cause iron deficiency anaemias and megaloblastic anaemia through folate and B12 deficiencies (Malik et al. 2012; Smith et al. 2017). Though this stems from malnutrition which comes under “nutrition,” likely as a result of direct or indirect climate-related natural disasters, haematological abnormalities can easily be framed through a climate change lens. Similarly, while cancer is likely to become the leading global cause of death, and there is an emerging body of literature highlighting the impact of climate change on cancer (Hiatt and Beyeler 2020), the oncology coverage was quite limited.

Additionally, the published LOs provide good coverage of the HICC on the dominant relevant body system, for example, the strong established link between air quality and respiratory health. There is still, however, room for growth in considering the broader impacts on other body systems, in line with emerging evidence. For example, the evidence now links poor air quality with neurological (Scieszka et al. 2022), cardiovascular (Chen et al. 2021), and renal systems (Hampton 2020). The published LOs represent an enormous amount of work from a broad range of authors, all seeking to improve healthcare in the context of climate change. Our analysis, however, highlights that there is significantly more work to be done.

Finally, in examining the authorship of these published papers, we find that the overwhelming majority of authors were Western and qualified in medicine or population health (or both). The key exception to this rule demonstrated a slightly different focus, including a range of LOs on the impacts of migration and cultural contexts on HICC. Given the importance of ensuring equitable, context-sensitive, and locally-driven approaches to medical education on global issues (Gosselin et al. 2016), there is a clear path to follow in building on the existing work.

Limitations

While we sought to review the available LOs in this area, we were naturally limited by a relatively extreme form of publication bias. That is, there is a trend toward the publication of teaching and learning innovations and practices; however, a substantial volume of curricula are designed, taught, assessed, evaluated, and revised well beyond the purview of the published literature. We have reviewed here only those LOs that have been published; as such, our review is limited in the commentary that can be made about how these topics are being taught and learned. To contextualise the scale of that issue, a review of the world’s medical schools approximated that there are more than 2600 medical schools in operation (Duvivier et al. 2014). We review here only 21 sets of LOs. Primary data collection by canvassing operating medical schools on their curricular coverage of the HICC and the sources from which they draw their LOs is necessary to provide a more comprehensive overview of how current medical students are being prepared for issues related to the HICC.

A second key limitation is that, owing to the practical limitations of author capacity, the papers for review were only included if they were published in English. This likely contributes to the finding that a disproportionate number of authors are working in WEIRD countries. As such, the authorship question needs further examination in the non-English language literature to develop a richer picture (Neimann Rasmussen and Montgomery 2018) of the topics and focus of LOs on HICC.

Conclusion

Medical education on the HICC is an active and emerging area of research. The current study reviews and synthesizes the published LOs to assess the focus of these. We do this with the specific intent of drawing out the coverage of biomechanism-related content to determine the degree to which this practical, clinically relevant knowledge is being included in teaching and learning about climate change. Our review indicates three key findings: 1) biomechanism-related content represents about a quarter of the published LOs, and these are focused on infectious disease, air quality, and extreme heat; 2) the published LOs represent only the tip of the iceberg, both in terms of what is being taught and what could be taught, and further research is needed to gain a clear picture of the teaching and learning in this area; and 3) there is a need for greater engagement with non-western and climate-vulnerable medical educators to develop and improve these curricula, especially as the HICC will be paramount in many developing countries who are most vulnerable to the effects of these climate changes.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Notes on contributors

Atul Sharma

Atul Sharma PhB, MChD student, School of Medicine and Psychology, College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory, Australia.

Lillian Smyth

Lillian Smyth, PhD, Senior Lecturer, School of Medicine and Psychology, College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory, Australia.

Holly Jian

Holly Jian, MPH, Senior Analyst. Australian Institute of Health and Welfare, Canberra, Australian Capital Territory, Australia.

Nicole Vargas

Nicole Vargas, PhD, Lecturer, School of Medicine and Psychology, College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory, Australia.

Devin Bowles

Devin Bowles, PhD, Lecturer, School of Medicine and Psychology, College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory, Australia.

Arnagretta Hunter

Arnagretta Hunter, MBBS, MPH, Clinical Senior Lecturer, School of Medicine and Psychology, College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory, Australia.