Climate Change in Undergraduate Medical Education: Gaps, Needs, and Opportunities for Curricular Reform

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Cunningham, Elizabeth Whidden, Jessica Campanile, Farah Hussain This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8816356/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background: Despite recognition of climate change as a key determinant of health, medical education on climate-health largely remains fragmented, elective-based, and focused more on knowledge than skills. At our institution, the Climate Change in Medicine elective course reaches only a small subset of students. To capture both course-specific outcomes and broader curricular needs, we paired an elective evaluation with a Community Strengths and Needs Assessment (CSNA) and subsequent focus groups. Methods: A mixed-methods study was conducted at a Mid-Atlantic medical school between September 2024 and May 2025. Pre- and post-course surveys were administered to students enrolled in a climate-health elective course to assess changes in knowledge, attitudes, and agency. A CSNA was distributed to the entire student body, and respondents subsequently participated in focus groups. Quantitative data were analyzed using paired t-tests and descriptive statistics; qualitative data were thematically analyzed. Results: Course participants (n = 14) demonstrated significant improvements across multiple domains. Self-reported knowledge increased from 4.21 to 5.28 on a 6-point Likert scale (p <0.001), while objective knowledge scores improved from 62.1% to 77.1% (p = 0.0025). Confidence in discussing climate-health during patient encounters rose from 3.50 to 5.07 on a 6-point Likert scale (p < 0.001), and confidence in advocating for community interventions increased from 3.57 to 4.93 (p < 0.001). Six months post-course students (n= 5) demonstrated persistence in students’ actions and self-efficacy regarding climate. The CSNA (n = 96) revealed limited prior exposure to climate-health education; only 38.5% of students reported at least some knowledge. However, 92.2% supported integrating climate-health into the medical curriculum. Reported barriers included lack of time (74.0%) and lack of confidence in discussing climate-health with patients (52.1%). Focus group participants (n = 14) emphasized the perceived clinical relevance of climate-health, the tension between individual and systemic action, and the need for equity-focused, clinically integrated curricula. Conclusions: This study demonstrates both the effectiveness of a climate-health elective in improving knowledge, confidence, and advocacy, and the significant unmet demand for broader curricular integration. Together, these findings highlight the potential of structured and accessible climate-health education to prepare future physicians. Figures Figure 1 Figure 2 Key Message What is already known on this topic. - Climate change poses significant health risks, yet climate-related education remains insufficiently integrated into medical curricula. Existing educational resources are often fragmented, lacking interactivity and clinical relevance, which leaves many students underprepared to counsel patients. What this study adds. - This study demonstrates that a brief, intensive elective can yield sustained improvements in medical students’ self-efficacy and climate-related actions, even six months after completion. Through surveys, focus groups, and a community strength and needs assessment, the findings also reveal strong student demand for climate-health education, alongside persistent gaps in preparedness and self-efficacy to put it into practice. Findings highlight the need for structured, interactive learning resources. How this study might affect research, practice or policy. - The results support the integration of climate health education into medical curricula, emphasizing the need for evidence-based, interactive approaches. Findings may inform medical education policies prioritizing climate literacy and interdisciplinary training in climate and health. Introduction Climate change is widely recognized as the greatest public health threat of the 21st century, with health impacts already evident across every region of the globe. 1 , 2 Notable examples of these health impacts include: rising global temperatures contributing to increased morbidity and mortality from heat-related illness, 3 degraded air quality exacerbating asthma, chronic obstructive pulmonary disease, and cardiovascular disease; 4 altered precipitation patterns and extreme weather events disrupting food and water systems, leading to malnutrition, diarrheal illness, and population displacement; 5 shifts in temperature and ecosystems expanding the geographic range of vector-borne diseases such as malaria, dengue, and Lyme disease. 6 , 7 , 8 Importantly, these burdens are not evenly distributed: children, older adults, people with chronic illness, low-income communities, and displaced populations face disproportionate and compounding risks, reflecting the structural inequities that shape vulnerability. 9 , 10 Collectively, these intersecting health impacts highlight not only the scale and complexity of the crisis but also the urgency of integrating climate change into the core of medical education so that physicians are equipped to meet the evolving needs of their patients and communities. The American Medical Association has issued policy statements supporting the integration of climate change into medical curricula, 11 and organizations such as the Association of American Medical Colleges, 12 The Lancet Countdown on Health and Climate Change, 13 and the Society of General Internal Medicine 14 have called for urgent physician training in climate-health competencies. Evidence from recent curricular innovations suggests that integrating climate and health education longitudinally across preclinical and clinical courses, incorporating competency-based frameworks, interactive case-based learning, reflective exercises, and opportunities for student-led advocacy can enhance knowledge, engagement, and agency among medical students. 15 , 16 , 17 , 18 Agency was defined as self-efficacy in applying climate-health concepts. Furthermore, embedding structural and equity-focused content is critical to prepare future physicians to address the disproportionate burden of climate-related health impacts on vulnerable populations. 18 However, most medical schools provide only limited instruction, typically through elective opportunities, and focus on knowledge-based over skills-based teaching. 19 Existing educational resources are often fragmented, narrowly focused, and lacking in interactivity or clinical relevance, limiting their impact on medical training. 19 This leaves the majority of students with uncertainty regarding how they take action. At the Perelman School of Medicine (PSOM), the elective course Climate Change in Medicine introduces students to climate-health actions to improve self-efficacy in professional, political and clinical spaces. However, participation is limited and as an elective, the course reaches only a small fraction of the student body. To better understand how medical education might address this gap, we designed a multi-part study that evaluated student learning outcomes from the elective and assessed the broader needs of the medical student community. This integrated approach linked elective outcomes with an assessment of school-wide needs, allowing our team to refine content to fill student-identified gaps. First, we evaluated learning outcomes among elective participants to measure changes in knowledge, attitudes, and agency. Recognizing, however, that a survey of elective students alone could not capture the perspectives of the wider student body, we then conducted a Community Strengths and Needs Assessment (CSNA) across the entire medical school to characterize interest, perceived relevance, and unmet needs in climate-health education. Finally, survey respondents were invited to participate in focus group discussions to further explore experiences with climate-related content and its relevance to clinical training. Methods Study Design This study included a quasi-experimental design to assess the implementation of a climate and health elective pilot followed by a cross-sectional study of students at PSOM using both a survey instrument and focus groups. The study was completed between September 2024 and May 2025. Setting and Population Students (n = 14) self-enrolled in the elective course Climate Change and Health , which took place in October 2024. Enrollment was open to all students at the medical school. The course consisted of a full-day session addressing the health impacts of climate change, policy considerations, sustainability practices, and climate-focused communication. It included lectures on pediatrics, cardiology, air pollution, reproductive care, infectious disease, and disability justice. Additional interactive sessions engaged students in climate advocacy as future healthcare providers, utilizing patient cases and healthcare sustainability examples. Most course components included an explicit environmental justice thread. All components were designed to emphasize actionable steps, and students received a list of resources and recommended actions following the course. The entire PSOM student body (n = 800) was invited to respond to the CSNA survey in November and December 2024. Recruitment was completed via emails as well as in-person events where team members shared information about the survey and distributed small climate-related items such as lapel pins, which were distributed whether or not a student confirmed completion of the survey. Students who completed the survey were then invited via email to participate in focus groups to gain additional insight. Student participants in the focus groups were provided with a free meal. Focus groups were completed in January and February 2025. Data Collection and Data Analysis Elective evaluation focused on student knowledge as well as agency, which was defined as the empowerment, initiative, and confidence of students in applying their learning. Three time-points were surveyed, immediately before the course, immediately after the course and 6 months after the course. Student’s class year, gender and race were collected in the pre-course survey. Both the pre- and both post- surveys included twelve 6-point Likert based questions assessing attitudes and perspectives, eleven 6-point Likert based questions on decision-making and practice, seven 6-point Likert-based questions assessing domains impacted by climate change, and 10 multiple choice questions assessing climate and health knowledge. A single question assessed perceived barriers to climate change patient education ( Supplementary Appendix ). Quantitative survey responses were analyzed with STATA BE.18. Descriptive statistics and the paired pre- and post-course scores were assessed for changes in knowledge, attitudes, and practice. The CSNA included 19 multiple-choice and Likert-scale items addressing prior engagement with climate-related content, perceived barriers to patient communication, preferred educational resources, and interest in specific topics ( Supplementary Appendix ). Quantitative survey responses were analyzed with STATA BE.18. The study included 3 semi-structured focus groups with 14 total participants, using an interview guide to prompt students to consider their exposure to climate-related health information, their sources of that information, and their experiences with the health impacts of climate change during clinical experiences. Participants were recruited via an opt-in question at the completion of the CSNA, thus all focus group participants completed the CSNA. Two participants in the focus group had previously completed the Climate Change and Health Elective, and twelve participants had not. These focus groups, led by one of the authors, were about one hour in length and audio recorded. The recordings were then transcribed, deidentified, and underwent thematic analysis in NVivo by one of the authors. Upon completion of a preliminary codebook and iterative discussion with the other authors, the themes described in this paper were synthesized from the qualitative data. Ethics approval and consent to participate Institutional Review Board (IRB) submission was completed and exempted by the University of Pennsylvania’s IRB (reference number: 857106). The need for consent to participate was waived by the IRB. Student confidentiality and data security were ensured throughout the study by hosting data on password-protected servers and de-identifying student data prior to analysis. Any compensation students received for participation in this study – such as a free meal or a lapel pin – were considered to be of minimal value and to not constitute undue influence on participants. Clinical number not applicable. Results Elective All 14 students completed the pre-course survey and the immediate post-course survey. 5 students completed the 6-months follow-up survey. Demographic information is presented in Table 1. Following completion of the elective course, students demonstrated significant improvements in knowledge, confidence, and attitudes related to climate change and health (Table 2). Self-reported knowledge about the relationship between climate change and health increased from a pre-course mean of 4.21 to a post-course mean of 5.28 on a 6-point Likert scale (p < 0.001). Students’ agreement that climate change is relevant to providing direct patient care also increased significantly (pre-course mean 5.07 to post-course mean 5.64, p =0.0142). Confidence in discussing the connection between climate change and health during patient interviews rose markedly, with mean scores increasing from 3.50 to 5.07 on a 6-point Likert scale (p < 0.001) (Figure 1). Students also expressed stronger beliefs that, as future physicians, they could contribute to the sustainable design of the health sector (pre-course mean 4.00 vs. post-course mean 4.86, p = 0.0011). Similarly, confidence in advocating for climate change interventions within their communities improved (pre-course mean 3.57 to post-course mean 4.93 (p < 0.001). In addition to these self-reported measures, an objective knowledge assessment demonstrated significant gains. Mean scores increased from 62.1% pre-course to 77.1% post-course (p = 0.0025), confirming measurable improvements in climate-health knowledge alongside enhanced confidence and attitudes. Six months after the course, students demonstrated the strongest persistence in changes to their practice and engagement, reporting continued self-efficacy across the following categories: how their actions can contribute to effective action on climate change, confidence in counseling patients, intervening in the community and contributing to the sustainable design of the healthcare sector. Notably, the persistence of attitudes and emotions was more limited. Together, these findings demonstrate that the course was associated with significant gains across all assessed domains, including knowledge, perceived relevance to clinical care, communication confidence, systems-level engagement, and advocacy. CSNA Respondent Characteristics A total of 96 medical students (12.7% of the student body) completed the survey, representing all class years (30% first-year, 26% second-year, 17% third-year, 17% fourth-year, and 10% combined-degree students). Respondents were predominantly female (62.5%) and White (45.8%). Other racial/ethnic groups included East Asian (22.9%), South Asian (13.5%), Hispanic/Latinx (7.3%), Black/African American (6.3%), and Southeast Asian (5.2%). Most students reported low to moderate engagement with climate-related activities both before and during medical school. Prior to medical school, 59.4% reported “low” or “none” engagement; during medical school, this increased slightly to 68.7%. The most frequently reported barriers were lack of time (74.0%) and lack of knowledge about how to discuss climate change with patients (52.1%). Other notable barriers included beliefs that discussion would not significantly impact health (19.8%) or that patients were not interested (18.8%). Several respondents highlighted additional challenges such as the emotional toll of the topic and lack of practical tools. Students expressed strong interest in structured training. The most frequently selected resources included: training on patient communication about climate and health (75.0%), waste disposal training during pre-clerkship (63.5%), healthcare sustainability training (60.4%), and advocacy training (57.3%). Fewer students endorsed interest in faculty research databases (27.1%) or a self-guided online curriculum (11.5%). Topics of Interest The most frequently selected content areas were: pollution and health consequences (20.8%), health disparities (16.7%), water and food insecurity (14.6%), cancer (12.5%) and infectious disease (11.5%). Topics of cardiovascular disease, mental health, heat-related illness, natural disasters, and population displacement were also suggested. Attitudes Toward Climate and Health in Medicine While only 38.5% of students felt at least somewhat knowledgeable about climate-health connections, the majority (82%) agreed that climate change is relevant to direct patient care (Figure 2). Nearly all respondents (92.2%) supported integrating climate-health content into the medical curriculum, underscoring the strong demand for formal education across class years. Although most students (78%) believed their personal and professional actions could contribute to climate action, far fewer expressed confidence in applying this knowledge in practice: only 18.8% felt confident counseling patients on climate-health issues, and 45.8% reported lacking confidence in discussing these topics during patient interviews. Focus groups A total of 14 students participated in three in-person focus groups, each lasting one hour and audio-recorded for analysis. Analysis of focus group discussions revealed several overarching themes related to medical students’ experiences with climate and health content, perceived barriers and facilitators to engagement, and perspectives on the role of physicians in addressing climate change. Students entered medical school with varying levels of knowledge about climate change; however, they did not feel that the current mainstream curriculum adequately filled in their knowledge gaps. Students reported varying exposure to climate-related content prior to medical school, most often through undergraduate coursework, gap-year experiences, or media sources. While some described entering medical school with a strong baseline understanding of climate change, others noted that the topic was rarely addressed in undergraduate coursework outside of elective classes. Students generally perceived that the mainstream medical school curriculum, particularly in the preclinical years, only superficially introduced climate-related topics, often framing them as issues of the future rather than immediate concern. Students expressed feelings of helplessness and futility when confronted with the enormity of climate change and its impacts on health, however found hope when engaged in discussions on climate advocacy and action. Students identified multiple barriers to engaging with climate-related information, including difficulty accessing reliable resources, limited curricular integration, and the overwhelming scope of the problem. Several participants described feelings of hopelessness, helplessness, or futility when confronted with the scale of climate change or the perceived mismatch between individual actions and systemic drivers. As one student expressed “I get that hopeless feeling a lot too… when I’m being told to use paper straws and there’s CEOs commuting on private jets to work, it’s like… what’s the point?” At the same time, facilitators using interactive teaching methods, clinically relevant framing, and opportunities to discuss concrete health impacts were reported to enhance engagement and motivation. Students noted considerable tension between individual and systems-level action against climate change. Participants frequently reflected on the contrast between individual behaviors (such as recycling, minimizing waste) and the outsized impact of institutional or corporate practices. Many expressed frustration that personal actions felt insufficient in the face of broader systemic drivers of climate change. This tension was particularly salient in the clinical learning environment, where students reported cognitive dissonance between their awareness of environmentally harmful practices (specifically operating room waste) and the entrenched culture and hierarchy that limited their ability to intervene. Student perspectives varied regarding the role of the physician in addressing climate change. Students voiced differing views on the appropriate role of physicians in addressing climate change. Some felt physicians should integrate climate considerations into patient counseling and advocacy, while others expressed discomfort or uncertainty about extending the physician role into broader societal and political domains. Students expressed interest in additional climate-health education, offering suggestions for curriculum development. Students offered concrete recommendations for improving climate-health education. These included integrating content longitudinally across preclinical and clinical courses, embedding climate considerations into patient cases and histories, and creating interactive, clinically oriented learning resources. Participants emphasized the value of framing climate change as a present and local issue, using examples immediately affecting their local patient population or hospital’s catchment area, as a way to make the material more relevant to their future clinical practice. Discussion By design, this study combined three complementary components: evaluation of a targeted elective, a needs assessment of the broader student body, and focus groups to contextualize quantitative findings. This mixed-methods approach provides a more comprehensive view of climate-health education at one institution and highlights the impact of an elective course to improve medical students’ knowledge of and engagement with climate change, identifying an opportunity to enhance the mainstream curriculum by filling student-identified gaps in current teaching. At the elective level, our findings are consistent with prior research demonstrating that even brief, intensive interventions can meaningfully enhance students’ knowledge of climate change and health and improve their communication skills when discussing climate change in their clinical work. 15,16,17,18 Our work affirms this evidence by demonstrating that gains in self-efficacy and climate-related actions persist even 6-months following the elective. These results suggest that climate-health education needs to reinforce the effects of climate change on human health and to equip learners with the skills and confidence to take action in talking with patients, reducing greenhouse gases from within the healthcare sector, and advocating in the community. 18 Consistent with prior surveys of medical students across the United States and internationally, 17, 18 our CSNA findings show significant gaps in exposure to climate-health content and preparedness to act on it and highlights a strong student interest in structured training on climate and health. While nearly all respondents agreed that climate change is relevant to patient care and should be integrated into medical education, fewer than one-fifth felt confident counseling patients on climate-health issues, and less than half reported even some knowledge of climate’s role in health. This disconnect between perceived importance and self-efficacy in the broader student body underscores the limitations of relying solely on elective coursework or limited mentions in the mainstream curriculum to provide future physicians with knowledge and skills related to climate change. While our elective proved impactful, only a small fraction of students opt to enroll in the course each year given logistical challenges and the multitude of competing demands medical students face. Together, these findings emphasize the importance of conducting local needs assessments to identify institution-specific strengths and barriers, while also reinforcing the need to integrate climate-health education throughout the core curriculum to ensure a broader reach. Similar barriers were identified by students in all investigated settings: limited time, lack of knowledge, and uncertainty about how to initiate climate-related conversations with patients. This reflects a challenge across medical education where emerging competencies require integration into already crowded and time-strained curricula. 20 The results of our CSNA further highlights these challenges, with the majority of students citing lack of time and lack of confidence as the most significant obstacles. Yet, despite these barriers, nearly all students favorably endorsed integrating climate-health content into the core curriculum. Importantly, students’ calls for interactive, clinically relevant resources suggest that fragmented content will not suffice. Embedding climate-health concepts longitudinally within existing courses, aligned with competency frameworks, reflective practice, and equity-focused content, has been shown to enhance both cognitive and affective learning domains while preparing students for actionable engagement in clinical and community contexts. 16 Qualitative findings from our focus groups also illuminate the emotive aspects of climate-health education. Students expressed feelings of helplessness and frustration when individual actions appeared trivial compared with systemic drivers of climate change. Focus group participants further emphasized the value of linking patient-level health impacts with broader systems considerations, underscoring the importance of clinically relevant and equity-focused framing when teaching this topic. Curricula that explicitly address both individual and institutional responsibilities through skills-based patient counseling, institutional sustainability initiatives, and advocacy may mitigate these feelings of futility while promoting empowerment and agency. Several limitations should be noted. This study was conducted at a single institution, which may limit generalizability. Respondents may also be self-selecting, representing students with greater baseline interest in climate change, despite the broad distribution of the CSNA across the entire medical school. In addition to selection bias, only 12% of students responded to the CSNA. The 6-month elective follow-up was also limited by a small sample size. Finally, our pre- and post- surveys relied on self-reported attitudes and practices, which may not fully capture objective competencies. The inclusion of a knowledge assessment, however, provides evidence that curricular interventions can drive measurable gains beyond perceptions alone. As noted, in prior research there still does not exist a validated tool that goes beyond learners’ knowledge to assess their attitudes and practices. Future research is needed to validate tools, such as the one used within our elective, within undergraduate medical education. Despite these limitations, this study contributes to the growing body of evidence that medical students overwhelmingly recognize climate change as a health issue and desire more comprehensive preparation. Building on these results, our long-term goal is to develop a comprehensive online climate-health curriculum that is interactive, evidence-based, and accessible to all students. This initiative, which we term PlanetaryRx, is designed to integrate climate change education into medical training in a clinically relevant and scalable way, with emphasis on health impacts, prevention strategies, and adaptive measures. By translating climate science into patient-centered clinical practice through modules that include case studies, public health data, and applied skills, the curriculum seeks to equip all graduating physicians with the knowledge and tools needed to care for patients in an era of rapid environmental change. Conclusions This study demonstrates that while medical students strongly endorse the integration of climate-health into medical training, substantial gaps in translating knowledge into action remain. Students recognize that climate change directly impacts patients, but need practical, time-efficient strategies to discuss these impacts in clinical settings. Integrating communication, advocacy, and sustainability into medical education not only enhances student knowledge and agency but also aligns with the student-reported interests in the health disparities of climate change, highlighting the need for a health equity lens. This perspective was consistently emphasized in the elective course and requested by students across the focus groups. Our findings show that even brief, structured curricular interventions can improve self-efficacy and promote sustained engagement in climate-related actions, demonstrating both the feasibility and impact of intentional climate-health education. Given the competing demands on medical students, relying solely on electives is insufficient. These results underscore the need for climate-health content to be longitudinally embedded throughout the curriculum, ensuring broad reach and normalization of climate-health competencies. By documenting student demand, identifying barriers, and quantifying the benefits of targeted teaching, this work underscores the need for scalable, competency-based approaches that embed climate-health across undergraduate medical education. These insights are directly guiding the development of PlanetaryRx , an evidence-based, student-centered curriculum designed to prepare future clinicians to navigate the intersection of climate, health, and equity in their practice. Abbreviations CSNA Community Strengths and Needs Assessment IRB International Review Board PSOM Perelman School of Medicine Declarations Ethics approval and consent to participate Institutional Review Board (IRB) approval was provided by the University of Pennsylvania. All research was conducted in accordance with the norms and standards of the University of Pennsylvania’s IRB. The need for consent to participate was waived by the IRB. Student confidentiality and data security were ensured throughout the study by hosting data on password-protected servers and de-identifying student data prior to analysis. Any compensation students received for participation in this study – such as a free meal or a lapel pin – were considered to be of minimal value and to not constitute undue influence on participants. Clinical number not applicable. All procedures involving human participants in this study were conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Consent for publication Not applicable. Availability of data and materials Focus group data generated or analysed during this study are included in this published article [and its supplementary information files]. The other datasets used and/or analysed during the current study can be made available by the corresponding author on a reasonable request. Competing Interests The authors declare no competing interests. Funding Funding was provided by the University of Pennsylvania Department of Medicine Undergraduate Medical Education Innovation Grant. Funders had a role in conceptualization but were not involved in data collection, analysis, decision to publish or preparation of the manuscript. Authors' contributions All authors were involved in the design of the study. PC designed and analyzed the quantitative surveys. EW analyzed the quantitative surveys. JC designed the focus group guide, PC and EW implemented the focus groups, and JC completed the analysis. PC and EW drafted the initial manuscript. All authors read and approved the final manuscript. Acknowledgements Thank you to Keith Hamilton MD, Caitlin Clancy MD MSHP, and Isha Thapar. References World Health Organization. (2018). Health and climate change: Update 2018. 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J Gen Intern Med. 2024;39(13):2581–9. https://doi.org/10.1007/s11606-024-08690-1 . Dalapati T, Alway EJ, Mantri S, Mitchell P, George IA, Kaplan S, Andolsek KM, Velkey JM, Lawson J, Muzyk AJ. Development of a curricular thread to foster medical students’ critical reflection and promote action on climate change, health, and equity. PLoS ONE. 2024;19(5):e0303615. https://doi.org/10.1371/journal.pone.0303615 . Kline MC, Malits JR, Baker N, Shirley H, Grobman B, et al. Climate Change, Environment, and Health: The implementation and initial evaluation of a longitudinal, integrated curricular theme and novel competency framework at Harvard Medical School. PLOS Clim. 2024;3(5):e0000412. https://doi.org/10.1371/journal.pclm.0000412 . Selvam R, Séguin N, Zhang L, et al. International planetary health education in medical training: A scoping review. J Graduate Med Educ. 2024;16(6S):58–68. https://doi.org/10.4300/JGME-D-24-00027.1 . Visser EH, Oosterveld B, Slootweg IA, Vos HMM, Adriaanse MA, Schoones JW, Brakema EA. The Development and Characteristics of Planetary Health in Medical Education: A Scoping Review. Acad medicine: J Association Am Med Colleges. 2024. 10.1097/ACM.0000000000005796 . Advance online publication. Hampshire K, Ndovu A, Bhambhvani H, Iverson N. Perspectives on climate change in medical school curricula—A survey of U.S. medical students. J Clim Change Health. 2021;4:100033. https://doi.org/10.1016/j.joclim.2021.100033 . Novilla MLB, Goates MC, Leffler T, Novilla NKB, Wu CY, Dall A, Hansen C. Integrating social care into healthcare: A review on applying the social determinants of health in clinical settings. Int J Environ Res Public Health. 2023;20(19):6873. https://doi.org/10.3390/ijerph20196873 . Tables Table 1. Characteristics of Climate Change and Health Elective Students. Characteristic N (%) Gender Male 2 (14.3%) Female 12 (85.7%) Race Black or African American 2 (14.3%) East Asian 6 (42.9%) Southeast Asian 1 (7.1%) White 7 (50.0%) Class Year Year 1 4 (28.6%) Year 2 5 (35.7%) Year 3 0 (0.0%) Year 4 4 (28.6%) Combined-degree or year out 1 (7.1%) Table 2a. How much do you think climate change will harm … Question Precourse (95% CI) Postcourse (95% CI) Postcourse 6-months (95% CI) You personally 5.21 (4.81 - 5.62) 5.57 (5.27 - 5.87) p = 0.0186 5.40 (4.72 - 6.08) p = 0.6213 Your patients 5.64 (5.36 - 5.93) 5.86 (5.65 - 6.07) p = 0.0823 5.40 (4.72 - 6.08) p = 3739 People in your country 5.64 (5.36 - 5.93) 5.86 (5.65 - 6.07) p = 0.0823 5.60 (4.92 - 6.28) p = 1.000 Future generations of people 5.93 (5.77 - 6.08) 6.00 (6.00 - 6.00) p = 0.3356 5.80 (5.24 - 6.35) p = 1.000 Table 2b. Attitudes and Perceptions Question Precourse (95% CI) Postcourse (95% CI) Postcourse 6-months (95% CI) I feel knowledgeable about the relationship between climate change and health. 4.21 (3.88 - 4.55) 5.28 (4.93 - 5.64) p <0.001 5.20 (4.64 - 5.75) p = 0.0993 Climate change has negatively impacted people in my city and/or county over the past decade. 4.92 (4.07 - 5.79) 5.78 (5.53 - 6.03) p =0.0166 5.80 (5.24 - 6.35) p = 0.3739 Climate change is relevant to providing direct patient care. 5.07 (4.54 - 5.60) 5.64 (5.36 - 5.93) p = 0.0142 5.20 (4.16 -6.23) p = 0.1778 The healthcare system does not significantly contribute to climate change. 1.5 (1.12 - 1.88) 1.5 (0.72 - 2.27) p = 1.00 1.20 (0.645 - 1.75) p = 0.1778 The Penn hospital system is well prepared for climate-related events (eg. disasters/emergencies, extreme weather events, increase in certain diseases) 2.93 (2.35 - 3.50) 2.78 (2.17 - 3.39) p = 0.500 2.60 ( 1.49 - 3.71) p = 0.6213 Teaching about climate change and its health impacts should be integrated into medical education. 5.54 (5.14 - 5.94) 5.84 (5.62 - 6.07) p = 0.139 5.20 (4.64 - 5.75) p = 0.1778 Science and technology will eventually solve our problems with pollution, overpopulation, and diminishing resources. 2.21 (1.57 - 2.86) 2.29 (1.59 - 2.98) p = 0.7753 2.00 (1.12 - 2.87) p = 0.0705 I feel powerless because individual healthcare providers cannot contribute as much to energy saving efforts as industries. 4.43 (3.65 - 5.20) 2.93 (2.27 - 3.59) p <0.001 4.2 (2.84 - 5.56) p = 0.3739 Table 2c. Practice and engagement Question Precourse (95% CI) Postcourse (95% CI) Postcourse 6-months (95% CI) I believe my actions, both personal and professional, can contribute to effective action on climate change. 4.00 (3.61 - 4.39) 4.86 (4.55 - 5.17) p <0.001 4.60 (3.49 - 5.71) p = 0.0161 I can see myself joining a climate focused organization. 4.79 (4.32 - 5.25) 5.14 (4.76 - 5.53) p = 0.0961 4.80 (4.24 - 5.36) Counseling patients on sustainable lifestyle choices is an important responsibility for physicians. 4.54 (4.14 - 4.93) 5.00 (4.51 - 5.49) p = 0.0821 4.00 (2.70 - 5.29) p = 1.00 Physicians should inform the general public about climate change. 4.50 (3.79 - 5.21) 5.14 (4.64 - 5.64) p = 0.0224 4.40 (3.29 - 5.51) p = 0.6213 I feel confident discussing the connection between climate change and health during patient interviews. 3.50 (2.96 - 4.04) 5.07 (4.65 - 5.49) p <0.001 5.00 (5.00 - 5.00) p = 0.0327 As a future physician, I believe I can contribute to the sustainable design of the health sector. 4.00 (3.40 - 4.60) 4.86 (4.41 - 5.30) p = 0.0011 4.40 (3.71 - 5.08) P = 0.0341 I feel confident advocating for climate change interventions in my community to protect the health of my future patients 3.57 (2.98 - 4.16) 4.93 (4.51 - 3.35) p <0.001 4.60 (3.92 - 5.28) p = 0.0046 Health professionals have a responsibility to bring the health effects of climate change to the attention of the public. 4.79 (4.10 - 5.47) 5.43 (4.99 - 5.87) p = 0.0135 4.80 (3.76 - 5.83) p = 0.0341 Health professionals have a responsibility to bring the health effects of climate change to the attention of policy makers 5.00 (4.40 - 5.60) 5.43 (5.06 - 5.80) p = 0.0823 5.00 (4.12 - 5.87) p = 0.0161 My professional society should offer virtual options for meetings and conferences to reduce travel-related emissions. 4.67 (3.93 - 5.40) 5.17 (4.41 - 5.92) p = 0.0261 5.50 (4.58 - 6.41) 0.0917 It is important to me that my future employer pays attention to the environmental performance of its company/institution 5.23 (4.79 - 5.67) 5.61 (5.31 - 5.92) p = 0.0180 5.40 (4.72 - 6.08) p = 0.3046 Additional Declarations No competing interests reported. Supplementary Files SupplementaryAppendixBMEClimate.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 18 May, 2026 Reviewers agreed at journal 18 May, 2026 Reviewers agreed at journal 18 May, 2026 Reviewers invited by journal 05 Mar, 2026 Editor assigned by journal 25 Feb, 2026 Submission checks completed at journal 25 Feb, 2026 First submitted to journal 25 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Cunningham","email":"data:image/png;base64,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","orcid":"","institution":"University of Pennsylvania","correspondingAuthor":true,"prefix":"","firstName":"Phoebe","middleName":"H.","lastName":"Cunningham","suffix":""},{"id":603316109,"identity":"9313855a-dcc2-4bba-9e8a-ed50bd13a22f","order_by":1,"name":"Elizabeth Whidden","email":"","orcid":"","institution":"University of Pennsylvania","correspondingAuthor":false,"prefix":"","firstName":"Elizabeth","middleName":"","lastName":"Whidden","suffix":""},{"id":603316111,"identity":"5bdc51ff-4410-4a4f-9255-4d62b199dd38","order_by":2,"name":"Jessica Campanile","email":"","orcid":"","institution":"University of Pennsylvania","correspondingAuthor":false,"prefix":"","firstName":"Jessica","middleName":"","lastName":"Campanile","suffix":""},{"id":603316112,"identity":"229b5498-5733-46d9-a665-21b0be2d94ac","order_by":3,"name":"Farah Hussain","email":"","orcid":"","institution":"University of Pennsylvania","correspondingAuthor":false,"prefix":"","firstName":"Farah","middleName":"","lastName":"Hussain","suffix":""}],"badges":[],"createdAt":"2026-02-07 14:54:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8816356/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8816356/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104413513,"identity":"4c1cb295-1207-45ce-ac92-683d6a3941ef","added_by":"auto","created_at":"2026-03-11 13:04:37","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":99869,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ePre- and post-course comparison to questions assessing attitudes and practices associated with climate change. ** p \u0026lt;0.001, * p\u0026lt;0.005\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8816356/v1/a5d4653e8abab1863ea44799.jpg"},{"id":104412367,"identity":"e022ed85-5122-4b61-b628-555775311f42","added_by":"auto","created_at":"2026-03-11 12:59:15","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":145613,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eCSNA attitudes of the UME student body represented through 6-point Likert score distributions.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8816356/v1/90c1776e819db3cc61503e85.jpg"},{"id":104416096,"identity":"492ac561-743b-4fb7-bc09-29e958205051","added_by":"auto","created_at":"2026-03-11 13:14:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":799318,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8816356/v1/dc434c76-a1c4-4503-8091-c8370ca7f9df.pdf"},{"id":104411998,"identity":"98a75e7c-6d6b-4f37-89cb-f31dd35b2324","added_by":"auto","created_at":"2026-03-11 12:58:27","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":15205,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryAppendixBMEClimate.docx","url":"https://assets-eu.researchsquare.com/files/rs-8816356/v1/bae284d843ab855a44cc2225.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Climate Change in Undergraduate Medical Education: Gaps, Needs, and Opportunities for Curricular Reform","fulltext":[{"header":"Key Message","content":"\u003cp\u003eWhat is already known on this topic.\u003c/p\u003e\n\u003cp\u003e-\u0026nbsp; \u0026nbsp; Climate change poses significant health risks, yet climate-related education remains insufficiently integrated into medical curricula. Existing educational resources are often fragmented, lacking interactivity and clinical relevance, which leaves many students underprepared to counsel patients.\u003c/p\u003e\n\u003cp\u003eWhat this study adds.\u003c/p\u003e\n\u003cp\u003e-\u0026nbsp; \u0026nbsp; This study demonstrates that a brief, intensive elective can yield sustained improvements in medical students’ self-efficacy and climate-related actions, even six months after completion. Through surveys, focus groups, and a community strength and needs assessment, the findings also reveal strong student demand for climate-health education, alongside persistent gaps in preparedness and self-efficacy to put it into practice. Findings highlight the need for structured, interactive learning resources.\u003c/p\u003e\n\u003cp\u003eHow this study might affect research, practice or policy.\u003c/p\u003e\n\u003cp\u003e- \u0026nbsp; \u0026nbsp;The results support the integration of climate health education into medical curricula, emphasizing the need for evidence-based, interactive approaches. Findings may inform medical education policies prioritizing climate literacy and interdisciplinary training in climate and health.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eClimate change is widely recognized as the greatest public health threat of the 21st century, with health impacts already evident across every region of the globe.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Notable examples of these health impacts include: rising global temperatures contributing to increased morbidity and mortality from heat-related illness,\u003csup\u003e3\u003c/sup\u003e degraded air quality exacerbating asthma, chronic obstructive pulmonary disease, and cardiovascular disease;\u003csup\u003e4\u003c/sup\u003e altered precipitation patterns and extreme weather events disrupting food and water systems, leading to malnutrition, diarrheal illness, and population displacement;\u003csup\u003e5\u003c/sup\u003e shifts in temperature and ecosystems expanding the geographic range of vector-borne diseases such as malaria, dengue, and Lyme disease.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Importantly, these burdens are not evenly distributed: children, older adults, people with chronic illness, low-income communities, and displaced populations face disproportionate and compounding risks, reflecting the structural inequities that shape vulnerability.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eCollectively, these intersecting health impacts highlight not only the scale and complexity of the crisis but also the urgency of integrating climate change into the core of medical education so that physicians are equipped to meet the evolving needs of their patients and communities. The American Medical Association has issued policy statements supporting the integration of climate change into medical curricula,\u003csup\u003e11\u003c/sup\u003e and organizations such as the Association of American Medical Colleges,\u003csup\u003e12\u003c/sup\u003e The Lancet Countdown on Health and Climate Change,\u003csup\u003e13\u003c/sup\u003e and the Society of General Internal Medicine\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e have called for urgent physician training in climate-health competencies.\u003c/p\u003e \u003cp\u003eEvidence from recent curricular innovations suggests that integrating climate and health education longitudinally across preclinical and clinical courses, incorporating competency-based frameworks, interactive case-based learning, reflective exercises, and opportunities for student-led advocacy can enhance knowledge, engagement, and agency among medical students.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Agency was defined as self-efficacy in applying climate-health concepts. Furthermore, embedding structural and equity-focused content is critical to prepare future physicians to address the disproportionate burden of climate-related health impacts on vulnerable populations.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e However, most medical schools provide only limited instruction, typically through elective opportunities, and focus on knowledge-based over skills-based teaching.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Existing educational resources are often fragmented, narrowly focused, and lacking in interactivity or clinical relevance, limiting their impact on medical training.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e This leaves the majority of students with uncertainty regarding how they take action.\u003c/p\u003e \u003cp\u003eAt the Perelman School of Medicine (PSOM), the elective course \u003cem\u003eClimate Change in Medicine\u003c/em\u003e introduces students to climate-health actions to improve self-efficacy in professional, political and clinical spaces. However, participation is limited and as an elective, the course reaches only a small fraction of the student body.\u003c/p\u003e \u003cp\u003eTo better understand how medical education might address this gap, we designed a multi-part study that evaluated student learning outcomes from the elective and assessed the broader needs of the medical student community. This integrated approach linked elective outcomes with an assessment of school-wide needs, allowing our team to refine content to fill student-identified gaps. First, we evaluated learning outcomes among elective participants to measure changes in knowledge, attitudes, and agency. Recognizing, however, that a survey of elective students alone could not capture the perspectives of the wider student body, we then conducted a Community Strengths and Needs Assessment (CSNA) across the entire medical school to characterize interest, perceived relevance, and unmet needs in climate-health education. Finally, survey respondents were invited to participate in focus group discussions to further explore experiences with climate-related content and its relevance to clinical training.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis study included a quasi-experimental design to assess the implementation of a climate and health elective pilot followed by a cross-sectional study of students at PSOM using both a survey instrument and focus groups. The study was completed between September 2024 and May 2025.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSetting and Population\u003c/h3\u003e\n\u003cp\u003eStudents (n\u0026thinsp;=\u0026thinsp;14) self-enrolled in the elective course \u003cem\u003eClimate Change and Health\u003c/em\u003e, which took place in October 2024. Enrollment was open to all students at the medical school. The course consisted of a full-day session addressing the health impacts of climate change, policy considerations, sustainability practices, and climate-focused communication. It included lectures on pediatrics, cardiology, air pollution, reproductive care, infectious disease, and disability justice. Additional interactive sessions engaged students in climate advocacy as future healthcare providers, utilizing patient cases and healthcare sustainability examples. Most course components included an explicit environmental justice thread. All components were designed to emphasize actionable steps, and students received a list of resources and recommended actions following the course.\u003c/p\u003e \u003cp\u003eThe entire PSOM student body (n\u0026thinsp;=\u0026thinsp;800) was invited to respond to the CSNA survey in November and December 2024. Recruitment was completed via emails as well as in-person events where team members shared information about the survey and distributed small climate-related items such as lapel pins, which were distributed whether or not a student confirmed completion of the survey. Students who completed the survey were then invited via email to participate in focus groups to gain additional insight. Student participants in the focus groups were provided with a free meal. Focus groups were completed in January and February 2025.\u003c/p\u003e\n\u003ch3\u003eData Collection and Data Analysis\u003c/h3\u003e\n\u003cp\u003eElective evaluation focused on student knowledge as well as agency, which was defined as the empowerment, initiative, and confidence of students in applying their learning. Three time-points were surveyed, immediately before the course, immediately after the course and 6 months after the course. Student\u0026rsquo;s class year, gender and race were collected in the pre-course survey. Both the pre- and both post- surveys included twelve 6-point Likert based questions assessing attitudes and perspectives, eleven 6-point Likert based questions on decision-making and practice, seven 6-point Likert-based questions assessing domains impacted by climate change, and 10 multiple choice questions assessing climate and health knowledge. A single question assessed perceived barriers to climate change patient education (\u003cem\u003eSupplementary Appendix\u003c/em\u003e). Quantitative survey responses were analyzed with STATA BE.18. Descriptive statistics and the paired pre- and post-course scores were assessed for changes in knowledge, attitudes, and practice.\u003c/p\u003e \u003cp\u003eThe CSNA included 19 multiple-choice and Likert-scale items addressing prior engagement with climate-related content, perceived barriers to patient communication, preferred educational resources, and interest in specific topics (\u003cem\u003eSupplementary Appendix\u003c/em\u003e). Quantitative survey responses were analyzed with STATA BE.18.\u003c/p\u003e \u003cp\u003eThe study included 3 semi-structured focus groups with 14 total participants, using an interview guide to prompt students to consider their exposure to climate-related health information, their sources of that information, and their experiences with the health impacts of climate change during clinical experiences. Participants were recruited via an opt-in question at the completion of the CSNA, thus all focus group participants completed the CSNA. Two participants in the focus group had previously completed the \u003cem\u003eClimate Change and Health\u003c/em\u003e Elective, and twelve participants had not. These focus groups, led by one of the authors, were about one hour in length and audio recorded. The recordings were then transcribed, deidentified, and underwent thematic analysis in NVivo by one of the authors. Upon completion of a preliminary codebook and iterative discussion with the other authors, the themes described in this paper were synthesized from the qualitative data.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eInstitutional Review Board (IRB) submission was completed and exempted by the University of Pennsylvania’s IRB (reference number: 857106). The need for consent to participate was waived by the IRB. Student confidentiality and data security were ensured throughout the study by hosting data on password-protected servers and de-identifying student data prior to analysis. Any compensation students received for participation in this study – such as a free meal or a lapel pin – were considered to be of minimal value and to not constitute undue influence on participants. Clinical number not applicable.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eElective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll 14 students completed the pre-course survey and the immediate post-course survey. 5 students completed the 6-months follow-up survey. Demographic information is presented in Table 1. Following completion of the elective course, students demonstrated significant improvements in knowledge, confidence, and attitudes related to climate change and health (Table 2). Self-reported knowledge about the relationship between climate change and health increased from a pre-course mean of 4.21 to a post-course mean of 5.28 on a 6-point Likert scale (p \u0026lt; 0.001). Students’ agreement that climate change is relevant to providing direct patient care also increased significantly (pre-course mean 5.07 to post-course mean 5.64, p =0.0142).\u003c/p\u003e\n\u003cp\u003eConfidence in discussing the connection between climate change and health during patient interviews rose markedly, with mean scores increasing from 3.50 to 5.07 on a 6-point Likert scale (p \u0026lt; 0.001) (Figure 1). Students also expressed stronger beliefs that, as future physicians, they could contribute to the sustainable design of the health sector (pre-course mean 4.00 vs. post-course mean 4.86, p = 0.0011). Similarly, confidence in advocating for climate change interventions within their communities improved (pre-course mean 3.57 to post-course mean 4.93 (p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eIn addition to these self-reported measures, an objective knowledge assessment demonstrated significant gains. Mean scores increased from 62.1% pre-course to 77.1% post-course (p = 0.0025), confirming measurable improvements in climate-health knowledge alongside enhanced confidence and attitudes.\u003c/p\u003e\n\u003cp\u003eSix months after the course, students demonstrated the strongest persistence in changes to their practice and engagement, reporting continued self-efficacy across the following categories: how their actions can contribute to effective action on climate change, confidence in counseling patients, intervening in the community and contributing to the sustainable design of the healthcare sector. Notably, the persistence of attitudes and emotions was more limited.\u003c/p\u003e\n\u003cp\u003eTogether, these findings demonstrate that the course was associated with significant gains across all assessed domains, including knowledge, perceived relevance to clinical care, communication confidence, systems-level engagement, and advocacy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCSNA\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRespondent Characteristics\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA total of 96 medical students (12.7% of the student body) completed the survey, representing all class years (30% first-year, 26% second-year, 17% third-year, 17% fourth-year, and 10% combined-degree students). Respondents were predominantly female (62.5%) and White (45.8%). Other racial/ethnic groups included East Asian (22.9%), South Asian (13.5%), Hispanic/Latinx (7.3%), Black/African American (6.3%), and Southeast Asian (5.2%).\u003c/p\u003e\n\u003cp\u003eMost students reported low to moderate engagement with climate-related activities both before and during medical school. Prior to medical school, 59.4% reported “low” or “none” engagement; during medical school, this increased slightly to 68.7%.\u003c/p\u003e\n\u003cp\u003eThe most frequently reported barriers were lack of time (74.0%) and lack of knowledge about how to discuss climate change with patients (52.1%). Other notable barriers included beliefs that discussion would not significantly impact health (19.8%) or that patients were not interested (18.8%). Several respondents highlighted additional challenges such as the emotional toll of the topic and lack of practical tools.\u003c/p\u003e\n\u003cp\u003eStudents expressed strong interest in structured training. The most frequently selected resources included: training on patient communication about climate and health (75.0%), waste disposal training during pre-clerkship (63.5%), healthcare sustainability training (60.4%), and advocacy training (57.3%). Fewer students endorsed interest in faculty research databases (27.1%) or a self-guided online curriculum (11.5%).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTopics of Interest\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe most frequently selected content areas were: pollution and health consequences (20.8%), health disparities (16.7%), water and food insecurity (14.6%), cancer (12.5%) and infectious disease (11.5%). Topics of cardiovascular disease, mental health, heat-related illness, natural disasters, and population displacement were also suggested.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAttitudes Toward Climate and Health in Medicine\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWhile only 38.5% of students felt at least somewhat knowledgeable about climate-health connections, the majority (82%) agreed that climate change is relevant to direct patient care (Figure 2). Nearly all respondents (92.2%) supported integrating climate-health content into the medical curriculum, underscoring the strong demand for formal education across class years. Although most students (78%) believed their personal and professional actions could contribute to climate action, far fewer expressed confidence in applying this knowledge in practice: only 18.8% felt confident counseling patients on climate-health issues, and 45.8% reported lacking confidence in discussing these topics during patient interviews.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFocus groups\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 14 students participated in three in-person focus groups, each lasting one hour and audio-recorded for analysis. Analysis of focus group discussions revealed several overarching themes related to medical students’ experiences with climate and health content, perceived barriers and facilitators to engagement, and perspectives on the role of physicians in addressing climate change.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStudents entered medical school with varying levels of knowledge about climate change; however, they did not feel that the current mainstream curriculum adequately filled in their knowledge gaps.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStudents reported varying exposure to climate-related content prior to medical school, most often through undergraduate coursework, gap-year experiences, or media sources. While some described entering medical school with a strong baseline understanding of climate change, others noted that the topic was rarely addressed in undergraduate coursework outside of elective classes. Students generally perceived that the mainstream medical school curriculum, particularly in the preclinical years, only superficially introduced climate-related topics, often framing them as issues of the future rather than immediate concern.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStudents expressed feelings of helplessness and futility when confronted with the enormity of climate change and its impacts on health, however found hope when engaged in discussions on climate advocacy and action.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStudents identified multiple barriers to engaging with climate-related information, including difficulty accessing reliable resources, limited curricular integration, and the overwhelming scope of the problem. Several participants described feelings of hopelessness, helplessness, or futility when confronted with the scale of climate change or the perceived mismatch between individual actions and systemic drivers. As one student expressed “I get that hopeless feeling a lot too… when I’m being told to use paper straws and there’s CEOs commuting on private jets to work, it’s like… what’s the point?” At the same time, facilitators using interactive teaching methods, clinically relevant framing, and opportunities to discuss concrete health impacts were reported to enhance engagement and motivation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStudents noted considerable tension between individual and systems-level action against climate change.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants frequently reflected on the contrast between individual behaviors (such as recycling, minimizing waste) and the outsized impact of institutional or corporate practices. Many expressed frustration that personal actions felt insufficient in the face of broader systemic drivers of climate change. This tension was particularly salient in the clinical learning environment, where students reported cognitive dissonance between their awareness of environmentally harmful practices (specifically operating room waste) and the entrenched culture and hierarchy that limited their ability to intervene.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStudent perspectives varied regarding the role of the physician in addressing climate change.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStudents voiced differing views on the appropriate role of physicians in addressing climate change. Some felt physicians should integrate climate considerations into patient counseling and advocacy, while others expressed discomfort or uncertainty about extending the physician role into broader societal and political domains.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStudents expressed interest in additional climate-health education, offering suggestions for curriculum development.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStudents offered concrete recommendations for improving climate-health education. These included integrating content longitudinally across preclinical and clinical courses, embedding climate considerations into patient cases and histories, and creating interactive, clinically oriented learning resources. Participants emphasized the value of framing climate change as a present and local issue, using examples immediately affecting their local patient population or hospital’s catchment area, as a way to make the material more relevant to their future clinical practice.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eBy design, this study combined three complementary components: evaluation of a targeted elective, a needs assessment of the broader student body, and focus groups to contextualize quantitative findings. This mixed-methods approach provides a more comprehensive view of climate-health education at one institution and highlights the impact of an elective course to improve medical students\u0026rsquo; knowledge of and engagement with climate change, identifying an opportunity to enhance the mainstream curriculum by filling student-identified gaps in current teaching. At the elective level, our findings are consistent with prior research demonstrating that even brief, intensive interventions can meaningfully enhance students\u0026rsquo; knowledge of climate change and health and improve their communication skills when discussing climate change in their clinical work.\u003csup\u003e15,16,17,18\u0026nbsp;\u003c/sup\u003eOur work affirms this evidence by demonstrating that gains in self-efficacy and climate-related actions persist even 6-months following the elective. These results suggest that climate-health education needs to reinforce the effects of climate change on human health and to equip learners with the skills and confidence to take action in talking with patients, reducing greenhouse gases from within the healthcare sector, and advocating in the community.\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eConsistent with prior surveys of medical students across the United States and internationally,\u003csup\u003e17, 18\u003c/sup\u003e our CSNA findings show significant gaps in exposure to climate-health content and preparedness to act on it and highlights a strong student interest in structured training on climate and health. While nearly all respondents agreed that climate change is relevant to patient care and should be integrated into medical education, fewer than one-fifth felt confident counseling patients on climate-health issues, and less than half reported even some knowledge of climate\u0026rsquo;s role in health. This disconnect between perceived importance and self-efficacy in the broader student body underscores the limitations of relying solely on elective coursework or limited mentions in the mainstream curriculum to provide future physicians with knowledge and skills related to climate change. While our elective proved impactful, only a small fraction of students opt to enroll in the course each year given logistical challenges and the multitude of competing demands medical students face. Together, these findings emphasize the importance of conducting local needs assessments to identify institution-specific strengths and barriers, while also reinforcing the need to integrate climate-health education throughout the core curriculum to ensure a broader reach.\u003c/p\u003e\n\u003cp\u003eSimilar barriers were identified by students in all investigated settings: limited time, lack of knowledge, and uncertainty about how to initiate climate-related conversations with patients. This reflects a challenge across medical education where emerging competencies require integration into already crowded and time-strained curricula.\u003csup\u003e20\u003c/sup\u003e The results of our CSNA further highlights these challenges, with the majority of students citing lack of time and lack of confidence as the most significant obstacles. Yet, despite these barriers, nearly all students favorably endorsed integrating climate-health content into the core curriculum. Importantly, students\u0026rsquo; calls for interactive, clinically relevant resources suggest that fragmented content will not suffice. Embedding climate-health concepts longitudinally within existing courses, aligned with competency frameworks, reflective practice, and equity-focused content, has been shown to enhance both cognitive and affective learning domains while preparing students for actionable engagement in clinical and community contexts.\u003csup\u003e16\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eQualitative findings from our focus groups also illuminate the emotive aspects of climate-health education. Students expressed feelings of helplessness and frustration when individual actions appeared trivial compared with systemic drivers of climate change. Focus group participants further emphasized the value of linking patient-level health impacts with broader systems considerations, underscoring the importance of clinically relevant and equity-focused framing when teaching this topic. Curricula that explicitly address both individual and institutional responsibilities through skills-based patient counseling, institutional sustainability initiatives, and advocacy may mitigate these feelings of futility while promoting empowerment and agency.\u003c/p\u003e\n\u003cp\u003eSeveral limitations should be noted. This study was conducted at a single institution, which may limit generalizability. Respondents may also be self-selecting, representing students with greater baseline interest in climate change, despite the broad distribution of the CSNA across the entire medical school.\u0026nbsp;In addition to selection bias, only 12% of students responded to the CSNA. The 6-month elective follow-up was also limited by a small sample size. Finally, our pre- and post- surveys relied on self-reported attitudes and practices, which may not fully capture objective competencies. The inclusion of a knowledge assessment, however, provides evidence that curricular interventions can drive measurable gains beyond perceptions alone. As noted, in prior research there still does not exist a validated tool that goes beyond learners\u0026rsquo; knowledge to assess their attitudes and practices. Future research is needed to validate tools, such as the one used within our elective, within undergraduate medical education.\u003c/p\u003e\n\u003cp\u003eDespite these limitations, this study contributes to the growing body of evidence that medical students overwhelmingly recognize climate change as a health issue and desire more comprehensive preparation. Building on these results, our long-term goal is to develop a comprehensive online climate-health curriculum that is interactive, evidence-based, and accessible to all students. This initiative, which we term PlanetaryRx, is designed to integrate climate change education into medical training in a clinically relevant and scalable way, with emphasis on health impacts, prevention strategies, and adaptive measures. By translating climate science into patient-centered clinical practice through modules that include case studies, public health data, and applied skills, the curriculum seeks to equip all graduating physicians with the knowledge and tools needed to care for patients in an era of rapid environmental change.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study demonstrates that while medical students strongly endorse the integration of climate-health into medical training, substantial gaps in translating knowledge into action remain. Students recognize that climate change directly impacts patients, but need practical, time-efficient strategies to discuss these impacts in clinical settings. Integrating communication, advocacy, and sustainability into medical education not only enhances student knowledge and agency but also aligns with the student-reported interests in the health disparities of climate change, highlighting the need for a health equity lens. This perspective was consistently emphasized in the elective course and requested by students across the focus groups.\u003c/p\u003e\n\u003cp\u003eOur findings show that even brief, structured curricular interventions can improve self-efficacy and promote sustained engagement in climate-related actions, demonstrating both the feasibility and impact of intentional climate-health education. Given the competing demands on medical students, relying solely on electives is insufficient. These results underscore the need for climate-health content to be longitudinally embedded throughout the curriculum, ensuring broad reach and normalization of climate-health competencies. By documenting student demand, identifying barriers, and quantifying the benefits of targeted teaching, this work underscores the need for scalable, competency-based approaches that embed climate-health across undergraduate medical education. These insights are directly guiding the development of \u003cem\u003ePlanetaryRx\u003c/em\u003e, an evidence-based, student-centered curriculum designed to prepare future clinicians to navigate the intersection of climate, health, and equity in their practice.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCSNA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommunity Strengths and Needs Assessment\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIRB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInternational Review Board\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePSOM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePerelman School of Medicine\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eInstitutional Review Board (IRB) approval was provided by the University of Pennsylvania. All research was conducted in accordance with the norms and standards of the University of Pennsylvania’s IRB.\u0026nbsp;The need for consent to participate was waived by the IRB.\u0026nbsp;Student confidentiality and data security were ensured throughout the study by hosting data on password-protected servers and de-identifying student data prior to analysis. Any compensation students received for participation in this study – such as a free meal or a lapel pin – were considered to be of minimal value and to not constitute undue influence on participants. Clinical number not applicable.\u003c/p\u003e\n\u003cp\u003eAll procedures involving human participants in this study were conducted in accordance with the ethical principles outlined in the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFocus group data generated or analysed during this study are included in this published article [and its supplementary information files]. The other datasets used and/or analysed during the current study can be made available by the corresponding author on a reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting Interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFunding was provided by the University of Pennsylvania Department of Medicine Undergraduate Medical Education Innovation Grant. Funders had a role in conceptualization but were not involved in data collection, analysis, decision to publish or preparation of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors' contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll authors were involved in the design of the study. PC designed and analyzed the quantitative surveys. EW analyzed the quantitative surveys. JC designed the focus group guide, PC and EW implemented the focus groups, and JC completed the analysis. PC and EW drafted the initial manuscript.\u0026nbsp;All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThank you to Keith Hamilton MD, Caitlin Clancy MD MSHP, and Isha Thapar.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. (2018). Health and climate change: Update 2018. 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Development of a curricular thread to foster medical students\u0026rsquo; critical reflection and promote action on climate change, health, and equity. PLoS ONE. 2024;19(5):e0303615. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0303615\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0303615\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKline MC, Malits JR, Baker N, Shirley H, Grobman B, et al. Climate Change, Environment, and Health: The implementation and initial evaluation of a longitudinal, integrated curricular theme and novel competency framework at Harvard Medical School. PLOS Clim. 2024;3(5):e0000412. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pclm.0000412\u003c/span\u003e\u003cspan address=\"10.1371/journal.pclm.0000412\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSelvam R, S\u0026eacute;guin N, Zhang L, et al. International planetary health education in medical training: A scoping review. J Graduate Med Educ. 2024;16(6S):58\u0026ndash;68. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4300/JGME-D-24-00027.1\u003c/span\u003e\u003cspan address=\"10.4300/JGME-D-24-00027.1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVisser EH, Oosterveld B, Slootweg IA, Vos HMM, Adriaanse MA, Schoones JW, Brakema EA. The Development and Characteristics of Planetary Health in Medical Education: A Scoping Review. Acad medicine: J Association Am Med Colleges. 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/ACM.0000000000005796\u003c/span\u003e\u003cspan address=\"10.1097/ACM.0000000000005796\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Advance online publication.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHampshire K, Ndovu A, Bhambhvani H, Iverson N. Perspectives on climate change in medical school curricula\u0026mdash;A survey of U.S. medical students. J Clim Change Health. 2021;4:100033. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.joclim.2021.100033\u003c/span\u003e\u003cspan address=\"10.1016/j.joclim.2021.100033\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNovilla MLB, Goates MC, Leffler T, Novilla NKB, Wu CY, Dall A, Hansen C. Integrating social care into healthcare: A review on applying the social determinants of health in clinical settings. Int J Environ Res Public Health. 2023;20(19):6873. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/ijerph20196873\u003c/span\u003e\u003cspan address=\"10.3390/ijerph20196873\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Characteristics of Climate Change and Health Elective Students.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"622\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e2 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e12 (85.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003eRace\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eBlack or African American\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e2 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eEast Asian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e6 (42.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eSoutheast Asian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e1 (7.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eWhite\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e7 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003eClass Year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eYear 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e4 (28.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 209px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eYear 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e5 (35.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eYear 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eYear 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e4 (28.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eCombined-degree or year out\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e1 (7.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2a. How much do you think climate change will harm \u0026hellip;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"621\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eQuestion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003ePrecourse (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003ePostcourse \u0026nbsp;(95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 196px;\"\u003e\n \u003cp\u003ePostcourse 6-months (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eYou personally\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e5.21 (4.81 - 5.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003e5.57 (5.27 - 5.87)\u003c/p\u003e\n \u003cp\u003ep = 0.0186\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 196px;\"\u003e\n \u003cp\u003e5.40 (4.72 - 6.08)\u003c/p\u003e\n \u003cp\u003ep = 0.6213\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eYour patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e5.64 (5.36 - 5.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003e5.86 (5.65 - 6.07)\u003c/p\u003e\n \u003cp\u003ep = 0.0823\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 196px;\"\u003e\n \u003cp\u003e5.40 (4.72 - 6.08)\u003c/p\u003e\n \u003cp\u003ep = 3739\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003ePeople in your country\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e5.64 (5.36 - 5.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003e5.86 (5.65 - 6.07)\u003c/p\u003e\n \u003cp\u003ep = 0.0823\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 196px;\"\u003e\n \u003cp\u003e5.60 (4.92 - 6.28)\u003c/p\u003e\n \u003cp\u003ep = 1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003eFuture generations of people\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e5.93 (5.77 - 6.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003e6.00 (6.00 - 6.00)\u003c/p\u003e\n \u003cp\u003ep = 0.3356\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 196px;\"\u003e\n \u003cp\u003e5.80 (5.24 - 6.35)\u003c/p\u003e\n \u003cp\u003ep = 1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 2b. Attitudes and Perceptions\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eQuestion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003ePrecourse (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003ePostcourse (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003ePostcourse 6-months (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eI feel knowledgeable about the relationship \u0026nbsp; \u0026nbsp; between climate change and health.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e4.21 (3.88 - 4.55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e5.28 (4.93 - 5.64)\u003c/p\u003e\n \u003cp\u003ep \u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e5.20 (4.64 - 5.75)\u003c/p\u003e\n \u003cp\u003ep = 0.0993\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eClimate change has negatively impacted people in my city and/or county over the past decade.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e4.92 (4.07 - 5.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e5.78 (5.53 - 6.03)\u003c/p\u003e\n \u003cp\u003ep =0.0166\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e5.80 (5.24 - 6.35)\u003c/p\u003e\n \u003cp\u003ep = 0.3739\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eClimate change is relevant to providing direct patient care.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e5.07 (4.54 - 5.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e5.64 (5.36 - 5.93)\u003c/p\u003e\n \u003cp\u003ep = 0.0142\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e5.20 (4.16 -6.23)\u003c/p\u003e\n \u003cp\u003ep = 0.1778\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eThe healthcare system does not significantly contribute to climate change.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e1.5 (1.12 - 1.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1.5 (0.72 - 2.27)\u003c/p\u003e\n \u003cp\u003ep = 1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e1.20 (0.645 - 1.75)\u003c/p\u003e\n \u003cp\u003ep = 0.1778\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eThe Penn hospital system is well prepared for climate-related events (eg. disasters/emergencies, extreme weather events, increase in certain diseases)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e2.93 (2.35 - 3.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e2.78 (2.17 - 3.39)\u003c/p\u003e\n \u003cp\u003ep = 0.500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e2.60 ( 1.49 - 3.71)\u003c/p\u003e\n \u003cp\u003ep = 0.6213\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eTeaching about climate change and its health impacts should be integrated into medical education.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e5.54 (5.14 - 5.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e5.84 (5.62 - 6.07)\u003c/p\u003e\n \u003cp\u003ep = 0.139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e5.20 (4.64 - 5.75)\u003c/p\u003e\n \u003cp\u003ep = 0.1778\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eScience and technology will eventually solve our problems with pollution, overpopulation, and diminishing resources.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e2.21 (1.57 - 2.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e2.29 (1.59 - 2.98)\u003c/p\u003e\n \u003cp\u003ep = 0.7753\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e2.00 (1.12 - 2.87)\u003c/p\u003e\n \u003cp\u003ep = 0.0705\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003eI feel powerless because individual healthcare providers cannot contribute as much to energy saving efforts as industries.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e4.43 (3.65 - 5.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e2.93 (2.27 - 3.59)\u003c/p\u003e\n \u003cp\u003ep \u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 119px;\"\u003e\n \u003cp\u003e4.2 (2.84 - 5.56)\u003c/p\u003e\n \u003cp\u003ep = 0.3739\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2c. Practice and engagement\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 286px;\"\u003e\n \u003cp\u003eQuestion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003ePrecourse (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003ePostcourse (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003ePostcourse 6-months (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 286px;\"\u003e\n \u003cp\u003eI believe my actions, both personal and professional, can contribute to effective action on climate change.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e4.00 (3.61 - 4.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e4.86 (4.55 - 5.17)\u003c/p\u003e\n \u003cp\u003ep \u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e4.60 (3.49 - 5.71)\u003c/p\u003e\n \u003cp\u003ep = 0.0161\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 286px;\"\u003e\n \u003cp\u003eI can see myself joining a climate focused organization.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e4.79 (4.32 - 5.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e5.14 (4.76 - 5.53)\u003c/p\u003e\n \u003cp\u003ep = 0.0961\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e4.80 (4.24 - 5.36)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 286px;\"\u003e\n \u003cp\u003eCounseling patients on sustainable lifestyle choices is an important responsibility for physicians.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e4.54 (4.14 - 4.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e5.00 (4.51 - 5.49)\u003c/p\u003e\n \u003cp\u003ep = 0.0821\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e4.00 (2.70 - 5.29)\u003c/p\u003e\n \u003cp\u003ep = 1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 286px;\"\u003e\n \u003cp\u003ePhysicians should inform the general public about climate change.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e4.50 (3.79 - 5.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e5.14 (4.64 - 5.64)\u003c/p\u003e\n \u003cp\u003ep = 0.0224\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e4.40 (3.29 - 5.51)\u003c/p\u003e\n \u003cp\u003ep = 0.6213\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 286px;\"\u003e\n \u003cp\u003eI feel confident discussing the connection between climate change and health during patient interviews.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e3.50 (2.96 - 4.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e5.07 (4.65 - 5.49)\u003c/p\u003e\n \u003cp\u003ep \u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e5.00 (5.00 - 5.00)\u003c/p\u003e\n \u003cp\u003ep = 0.0327\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 286px;\"\u003e\n \u003cp\u003eAs a future physician, I believe I can contribute \u0026nbsp;to the sustainable design of the health sector.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e4.00 (3.40 - 4.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e4.86 (4.41 - 5.30)\u003c/p\u003e\n \u003cp\u003ep = 0.0011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e4.40 (3.71 - 5.08)\u003c/p\u003e\n \u003cp\u003eP = 0.0341\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 286px;\"\u003e\n \u003cp\u003eI feel confident advocating for climate change interventions in my community to protect the health of my future patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e3.57 (2.98 - 4.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e4.93 (4.51 - 3.35)\u003c/p\u003e\n \u003cp\u003ep \u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e4.60 (3.92 - 5.28)\u003c/p\u003e\n \u003cp\u003ep = 0.0046\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 286px;\"\u003e\n \u003cp\u003eHealth professionals have a responsibility to bring the health effects of climate change to the attention of the public.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e4.79 (4.10 - 5.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e5.43 (4.99 - 5.87)\u003c/p\u003e\n \u003cp\u003ep = 0.0135\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e4.80 (3.76 - 5.83)\u003c/p\u003e\n \u003cp\u003ep = 0.0341\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 286px;\"\u003e\n \u003cp\u003eHealth professionals have a responsibility to bring the health effects of climate change to the attention of policy makers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e5.00 (4.40 - 5.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e5.43 (5.06 - 5.80)\u003c/p\u003e\n \u003cp\u003ep = 0.0823\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e5.00 (4.12 - 5.87)\u003c/p\u003e\n \u003cp\u003ep = 0.0161\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 286px;\"\u003e\n \u003cp\u003eMy professional society should offer virtual options for meetings and conferences to reduce travel-related emissions.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e4.67 (3.93 - 5.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e5.17 (4.41 - 5.92)\u003c/p\u003e\n \u003cp\u003ep = 0.0261\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e5.50 (4.58 - 6.41)\u003c/p\u003e\n \u003cp\u003e0.0917\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 286px;\"\u003e\n \u003cp\u003eIt is important to me that my future employer pays attention to the environmental performance of its company/institution\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e5.23 (4.79 - 5.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e5.61 (5.31 - 5.92)\u003c/p\u003e\n \u003cp\u003ep = 0.0180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e5.40 (4.72 - 6.08)\u003c/p\u003e\n \u003cp\u003ep = 0.3046\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8816356/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8816356/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003cbr\u003e\n \u003c/strong\u003eDespite recognition of climate change as a key determinant of health, medical education on climate-health largely remains fragmented, elective-based, and focused more on knowledge than skills. At our institution, the \u003cem\u003eClimate Change in Medicine \u003c/em\u003eelective course reaches only a small subset of students. To capture both course-specific outcomes and broader curricular needs, we paired an elective evaluation with a Community Strengths and Needs Assessment (CSNA) and subsequent focus groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003cbr\u003e\n \u003c/strong\u003eA mixed-methods study was conducted at a Mid-Atlantic medical school between September 2024 and May 2025. Pre- and post-course surveys were administered to students enrolled in a climate-health elective course to assess changes in knowledge, attitudes, and agency. A CSNA was distributed to the entire student body, and respondents subsequently participated in focus groups. Quantitative data were analyzed using paired t-tests and descriptive statistics; qualitative data were thematically analyzed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003cbr\u003e\n \u003c/strong\u003eCourse participants (n = 14) demonstrated significant improvements across multiple domains. Self-reported knowledge increased from 4.21 to 5.28 on a 6-point Likert scale (p \u0026lt;0.001), while objective knowledge scores improved from 62.1% to 77.1% (p = 0.0025). Confidence in discussing climate-health during patient encounters rose from 3.50 to 5.07 on a 6-point Likert scale (p \u0026lt; 0.001), and confidence in advocating for community interventions increased from 3.57 to 4.93 (p \u0026lt; 0.001). Six months post-course students (n= 5) demonstrated persistence in students’ actions and self-efficacy regarding climate.\u003c/p\u003e\n\u003cp\u003eThe CSNA (n = 96) revealed limited prior exposure to climate-health education; only 38.5% of students reported at least some knowledge. However, 92.2% supported integrating climate-health into the medical curriculum. Reported barriers included lack of time (74.0%) and lack of confidence in discussing climate-health with patients (52.1%). Focus group participants (n = 14) emphasized the perceived clinical relevance of climate-health, the tension between individual and systemic action, and the need for equity-focused, clinically integrated curricula.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003cbr\u003e\n \u003c/strong\u003eThis study demonstrates both the effectiveness of a climate-health elective in improving knowledge, confidence, and advocacy, and the significant unmet demand for broader curricular integration. Together, these findings highlight the potential of structured and accessible climate-health education to prepare future physicians.\u003c/p\u003e","manuscriptTitle":"Climate Change in Undergraduate Medical Education: Gaps, Needs, and Opportunities for Curricular Reform","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-11 12:01:08","doi":"10.21203/rs.3.rs-8816356/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-18T18:21:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"108410539715559360137659370823234704831","date":"2026-05-18T14:43:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"305099805011785852601274762938071202561","date":"2026-05-18T13:51:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-05T15:21:37+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-26T04:17:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-25T12:49:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2026-02-25T12:43:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"07a9ed42-8ff9-4e42-a687-553570176ecd","owner":[],"postedDate":"March 11th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-18T18:21:18+00:00","index":105,"fulltext":""},{"type":"reviewerAgreed","content":"108410539715559360137659370823234704831","date":"2026-05-18T14:43:31+00:00","index":104,"fulltext":""},{"type":"reviewerAgreed","content":"305099805011785852601274762938071202561","date":"2026-05-18T13:51:52+00:00","index":103,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-11T12:01:08+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-11 12:01:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8816356","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8816356","identity":"rs-8816356","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}