Identification of core objectives for teaching sustainable healthcare education

Figures & data

Table 1. Demographic characteristics of 52 experts participating in a modified Delphi survey of sustainable healthcare education (SHE) objectives for inclusion in medical education.

Characteristic	Category	Mean (%)
Country	United States	40 (76.9)
	United Kingdom	8 (15.4)
	Australia	2 (3.8)
	Canada	1 (1.9)
	India	1 (1.9)
Profession	Physicians	29 (55.8)
	Physicians with additional degree (e.g., MPH)	10 (19.2)
	PhD	11 (21.2)
	Other (e.g., MPH, MSW)	2 (3.8)
Affiliation	Public university	26 (50)
	Private university	15 (28.8)
	Health system	4 (7.7)
	Non-profit organization	4 (7.7)
	Government organization	3 (5.8)
SHE expertise^a	Research	26 (50)
	Activism	21 (40.4)
	Teaching	14 (26.9)
	Administration	10 (19.2)
	Writing/publishing	6 (11.5)

^aRespondents were allowed to select multiple categories

Table 2. Mean rating, content validity index (CVI), and mode of time period in training for proposed sustainable healthcare education (SHE) objectives as rated by 52 experts during a modified Delphi procedure.

Objective	Mean rating^a (SD)	CVI for ratings of 3 or 4 %^b	Mode for training time period^c
Describe how the environment and human health interact at different levels (Doctor as scholar and scientist)
Outline the dependence of human health on global and local ecological systems, which supply essentials such as air, water, and a stable climate	3.75 (.52)	96	2
Describe the mechanisms by which human health is affected by environmental change, for example through changes in disease vectors, exposure to extreme weather, migration, and reduced food security.	3.73 (.53)	96	2
Describe features of a health-promoting local environment, in community and healthcare settings, to include access to green spaces, clean air, and an active travel infrastructure	3.46 (.67)	90	2
Discuss the contribution of human activity and population size to global environmental changes such as climate change, biodiversity loss, and resource depletion	3.42 (.79)	87	2
Explain the concept of environmental justice and the core principles for addressing it	3.25 (.97)	81	2
Discuss medical, ethical, legal, and economic factors in caring for patients with environmental disease	3.25 (.86)	81	3
Demonstrate the knowledge and skills needed to improve the environmental sustainability of health systems (Doctor as practitioner)
Identify ways to improve the environmental sustainability of health systems – in individual practice, in health service management, and in the design of care systems	3.38 (.80)	88	4
Identify potential synergies between policies and practices that promote environmental sustainability and those that promote health	3.34 (.90)	87	2
Define environmental sustainability	3.33 (.79)	85	1
Take a focused occupational and environmental history	3.33 (.73)	85	3
Explain how trends in demographics, technology, climate, and resource availability may affect our ability to provide healthcare into the future	3.13 (.90)	79	2
Describe, with examples, the different types of environmental impact resulting from healthcare provision, and how these may be measured	3.17 (.81)	79	3
Diagnose, treat, and/or prevent adverse health effects to attributable to global climate change or environmental causes (e.g., illness from extreme weather conditions, disease vectors, inspired air pollutants - in particular ozone, particulate matter, and/or ingested pollutants from food or water)	3.17 (.90)	75	3
Explain bioaccumulation and biomagnification of pollutants	2.92 (.93)	69	2
Identify patients most vulnerable to climate change and advise them accordingly	2.88 (1.00)	63	3
Discuss how the duty of a doctor to protect and promote health is shaped by the dependence of human health on the local and global environment. (Doctor as professional)
Discuss ethical tensions between allocating resources to individual patients and protecting the environment upon which the health of the wider community depends	3.25 (.72)	83	2
Evaluate their work environment for level of sustainability	3.06 (.78)	81	3
Explain how the health impacts of environmental change are distributed unequally within and between populations and the disparity between those most responsible and those most affected by change	3.21 (.82)	79	2
Discuss competing interests within healthcare (cost, infection control, safety) contributing to environmental inefficiency	3.23 (.85)	77	2
Recognize and articulate personal values concerning environmental sustainability, given the relationship between the environment and the health of current and future generations	3.00 (.79)	73	2
Demonstrate awareness of organizational sustainability policies and the legal frameworks for reducing carbon emissions	2.79 (.87)	58	2

^aScale: 1 = not important; do not include, 2 = moderately important, 3 = important, 4 = very important.

^bThe CVI represents respondents who rated this objective as 3 (important) or 4 (very important).

^cScale: 1 = prior to medical school, 2 = preclinical years of medical school, 3 = clinical years of medical school, 4 = postgraduate years

Table 3. Core set of objectives for teaching sustainable healthcare education (SHE) and timing in medical education during which to impart each objective as recommended by 52 experts during a modified Delphi procedure.

Domain	Doctor as scholar and scientist	Doctor as practitioner	Doctor as professional
Prior to medical school	–	Define environmental sustainability	–
Pre-clinical Years of medical school	- Outline the dependence of human health on global and local ecological systems, which supply essentials such as air, water, and a stable climate - Describe the mechanisms by which human health is affected by environmental change, for example through changes in disease vectors, exposure to extreme weather, migration, and reduced food security. - Describe features of a health-promoting local environment, in community and healthcare settings, to include access to green spaces, clean air and an active travel infrastructure - Discuss the contribution of human activity and population size to global environmental changes such as climate change, biodiversity loss and resource depletion - Explain the concept of environmental justice and the core principles for addressing it	- Identify potential synergies between policies and practices that promote environmental sustainability and those that promote health - Explain how trends in demographics, technology, climate, and resource availability may affect our ability to provide healthcare into the future	- Discuss ethical tensions between allocating resources to individual patients and protecting the environment upon which the health of the wider community depends - Explain how the health impacts of environmental change are distributed unequally within and between populations and the disparity between those most responsible and those most affected by change
Clinical years of medical school	- Discuss medical, ethical, legal, and economic factors in caring for patients with environmental disease	- Take a focused occupational and environmental history - Describe, with examples, the different types of environmental impact resulting from healthcare provision, and how these may be measured	- Evaluate their work environment for level of sustainability
Post-graduate years	–	- Identify ways to improve the environmental sustainability of health systems – in individual practice, in health service management, and in the design of care systems	–

Non-core objectives for inclusion:

1. Diagnose, treat, and/or prevent adverse health effects attributable to global climate change or environmental causes (e.g., illness from extreme weather conditions, disease vectors, inspired air pollutants - in particular ozone, particulate matter, and/or ingested pollutants from food or water).

2. Explain bioaccumulation and biomagnification of pollutants

3. Identify patients most vulnerable to climate change and advise them accordingly

4. Discuss competing interests within healthcare (cost, infection control, safety) contributing to environmental inefficiency

5. Recognize and articulate personal values concerning environmental sustainability, given the relationship between the environment and the health of current and future generations

6. Demonstrate awareness of organizational sustainability policies and the legal frameworks for reducing carbon emissions