ABSTRACT

Extreme heat and higher temperatures driven by climate change have increased the utilization of the emergency department by contributing to a range of illnesses and excess mortality, particularly in urban areas and for vulnerable populations. The Climate Change and Environmental Health thread was formally added to the Emory School of Medicine curriculum in 2022 to address the challenge of educating medical students on the link between climate change and the health of their patients. The formalization of this thread throughout the 4-year curriculum led to new content integration into the clerkship years. The Thread Director, student leadership, Emergency Medicine. Clerkship leadership, and the School of Medicine Human Simulation Education Center team collaborated to update an existing emergency medicine Observed Structured Clinical Examination to assess learners on their retention and application of climate change and environmental health knowledge and skills related to heat illness. Future work will include a more robust rubric for the assessment and evaluation of the students’ discharge planning counseling.

INTRODUCTION

Extreme heat and higher temperatures driven by climate change contribute to increased utilization of emergency departments, a widening range of illnesses, and excess mortality  

(Vaidyanathan, Gates, Brown, Prezzato, & Bernstein, 2024). Illnesses directly caused by heat exposure include heat exhaustion, heat stroke, rhabdomyolysis, and hyperthermia (Faurie, Varghese, Liu, & Bi, 2022).  Heat exposure can also cause acute worsening of chronic diseases including chronic obstructive pulmonary disease, cardiovascular disease, renal disease, and neurovascular disease as well as contribute to an increased incidence of trauma and violence (Girma, Liu, Schinasi, Clougherty, & Sheffield, 2023; Hayden et al., 2023). 

Extreme heat is intensified in urban areas due to the urban heat island effect (Mohajerani, Bakaric, & Jeffrey-Bailey, 2017). Relatively less green space to dissipate heat and relatively more man-made structures that absorb heat contribute to temperatures in cities that are 15-20°F hotter than surrounding neighborhoods (Climate Central, 2021).  In fact, since 2000 Atlanta has experienced, on average, a more than doubling of extreme heat days in the summer months, lengthening of heat waves, and an earlier seasonal onset and later seasonal resolution of extreme heat. (ARC Research, 2024).

Extreme heat exposure risk further increases for individuals who work or exercise strenuously outdoors as well as those living in neighborhoods with compounding environmental stressors, including a high concentration of heat-absorbing infrastructure, asphalt and industry (Hoffman, Shandas, & Pendleton, 2020).  Vulnerability increases for individuals who are unprepared for, unaware of, or unable to access protective measures (e.g. heat action plans, air conditioning, safe housing, hydration breaks) or community resources (e.g., social support systems, cooling centers, energy-assistance programs) for extreme heat events (Derakhshan, Eisenman, Basu, & Longcore, 2024). Physiologically, the risk of harm from extreme heat is amplified for individuals who are very young or very old, pregnant individuals, and those with existing chronic conditions or healthcare needs (Hayden et al., 2023).

Physicians in emergency departments across Atlanta are likely to continue to see an increased frequency and severity of heat-related illnesses.  But the risks of illness from extreme heat also resonate beyond Atlanta, with 87% of the US population projected to live in cities by 2050 (United Nations Department of Economic and Social Affairs, 2019).  With climate change and extreme heat posing a serious and increasing threat to patients, health professional students require training on recognizing, assessing, and addressing illnesses related to extreme heat as well as counseling patients on strategies to prevent harm and reduce risks upon discharge from the emergency department.  This climate reality provided an opportunity to develop a curriculum and embed it within an existing required medical school Emergency Medicine (EM) clinical clerkship.

THE THREAD

The Climate Change and Environmental Health (CCEH) thread grew out of a faculty and student partnership to co-create and disseminate CCEH content throughout the pre-clinical phase of the Emory University School of Medicine (EUSOM) curriculum starting in 2020 (Rabin, Laney, & Philipsborn, 2020). Formally added to the medical student curriculum in 2022, the thread aims to prepare students to recognize, assess, address—and ultimately prevent—environmental health challenges faced by patients.  The thread educates medical students on ways in which environmental factors, including climate change-driven exposures, influence the pathophysiology of disease as well as patient risk factors, disease courses, and plans of care.

In focus groups conducted to evaluate the pre-clinical CCEH curriculum, students reflected on the integration of heat illness, with one stating, “When they showed the map with the redlining, and how it overlapped perfectly with the map of the high incidence of heat stroke and the ambient temperature being higher, I think that really impacted me” (Liu, Rabin, Manivannan, Laney, & Philipsborn, 2022). Students also requested more emphasis on the application of CCEH content to direct patient care, clinical rotations, and clinical decision-making.  While pre-clinical students described climate change as “something that you consider in your daily practice… and hopefully moving forward as a physician” (Liu et al., 2022), the degree to which they retain this perspective and incorporate climate-informed principles into patient care as they advance through clinical clerkships is unknown.  In response to student suggestions and following formalization of the thread, the CCEH team began integrating didactic content and formative evaluation into the clerkship years.

THE CLERKSHIP

The EUSOM Emergency Medicine clerkship is a required four-week fourth-year rotation during which medical students synthesize and apply knowledge gained in the first three years of medical school to evaluate and manage undifferentiated patients in the emergency department. While the EM Clerkship historically included didactics on environmental emergencies, the EM and CCEH leadership recognized an opportunity to enhance EM-CCEH content related to extreme heat and to leverage existing EM assessment strategies to assess learners’ application of this content. The integration and application of CCEH content in EM builds upon the content covered earlier in the medical school curriculum. 

ASSESSMENT GAPS

Even as the CCEH Thread continues to weave content throughout the curriculum for medical students, learner assessment strategies have lagged.  Learner assessments for the CCEH thread, like CCEH content, are integrated into the pre-clinical course or clinical clerkship in which content is delivered.  Most assessment strategies implemented to date are lower on Miller’s Pyramid of clinical skills development (Miller, 1990).  For example, Goel et al. discuss assessment strategies in the pre-clinical Pulmonary course that, while well-matched to pre-clinical content, assess learner recall of key content on multiple-choice questions and interpretation and application of key content on a short essay question (Goel, Emanuels, Philipsborn, & Mehta, 2025), but not students’ ability to apply their knowledge in real patient care situations.  Overall, the CCEH Thread lacked assessments that required demonstration of knowledge and skills in either the clinical environment or in simulated patient encounters. 

This challenge for Emory’s CCEH curriculum reflects a challenge for the field as a whole. While the majority of medical schools now include content on climate change and health in required curricula, data on whether and how students are assessed on this content is lacking.  To date, most curriculum publications on climate change employ learner self-assessment, short answer quizzes, and pre- and post-activity assessments.  In one exception, educators developed a standardized patient case on wildfire exposure as a risk for asthma exacerbation and implemented it in an observed structured clinical examination (OSCE) in which learners interacted with trained actors known as standardized patients (SPs) (Ramkumar, Rosencranz, & Herzog, 2021).  This assessment was part of a single exercise rather than a course, but their experience suggests the feasibility and acceptability of including climate-related risk factors in OSCEs as a tool to assess learner competencies, and by extension, towards ultimately evaluating curricular outcomes.

THE OSCE

At Emory, the CCEH Thread Director, CCEH student leadership, and EM Clerkship leadership agreed that an OSCE would provide an excellent opportunity for assessing students completing the EM Clerkship, and that doing so was feasible, as they already employed an evaluation at the conclusion of the clerkship in the form of three SP encounters. One of the case scenarios revolved around a patient who presents to the emergency department with an asthma exacerbation.  This case was revised to facilitate assessment of students’ ability to identify the patient’s risk for health harms from climate change and to incorporate components of climate-related health counseling in their approach to standardized patients.

Once goals for the assessment were identified, the team collaborated with the Human Simulation Education Center (HSEC) at EUSOM to hone the case stimulus, which is used to supply students with information required for the case and to develop training materials for the SPs.  The case scenario was updated to incorporate CCEH triggers of asthma (in this case, extreme heat and air pollution) in the history of present illness.  The simulation is structured to occur in a heat wave, and learners are presented with weather and climate data, including daily temperature minimums and maximums as well as daily maximum air quality indices, for the five days preceding the simulated patient’s presentation to the emergency department (Figure 1).