PCLM-D-23-00235

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 Climate

Dear Dr. Basu,

Thank you for submitting your manuscript to PLOS Climate. After careful consideration, we feel that it has merit but does not fully meet PLOS Climate’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Apr 04 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at climate@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pclm/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

We look forward to receiving your revised manuscript.

Kind regards,

Sherilee L. Harper, PhD

Academic Editor

PLOS Climate

Journal Requirements:

1. May we please request of copy editing.

Additional Editor Comments (if provided):

Thank you for submitting your article to the journal. It covers an important topic.

After reading the reviewer comments, and based on my own assessment of the article, I would like to invite you to make revisions to your article.

In addition to the great and helpful comments of the reviewers, it would be helpful if could you also please include information in the article about your ethics approvals and any important ethical details.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does this manuscript meet PLOS Climate’s publication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS Climate does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: My thanks to the authors for their commendable development of what appears to be a leading example of integrating climate change into medical education. In general, the paper is well-written, and compelling in terms of how it has documented the success of the program's rollout. I have two major suggestions for revision and several minor suggestions that would significantly enhance the manuscript and increase its suitability for publication in PLOS Climate:

Major issues:

There is a slightly problematic orientation of the authors in labeling what they’ve done as particularly novel and inventive, primarily because of under engagement with the ever-growing literature on this topic, much of which did not seem to be considered during the planning and implementation phase. This is not to take away from what I do believe is an exemplary mainstreaming of climate into Harvard's medical program which is a significant contribution. However, in terms of the manuscript, there are opportunities to recast and reposition the exemplary contribution to medical education that is articulated in this contribution by better placing it in context of other empirical and conceptual work around climate change core competencies and expanded opportunities for medical education (including public health and nursing professions) which would be a bit more mindful of past precedent in this space. Cross-referencing the extant literature, and more importantly, identifying existing gaps and opportunities to further strengthen your curriculum (or at least make recommendations to others based on which gaps emerge from a more adequate review of the literature, for example) would significantly enhance the utility and communicative potential of your paper. Such a review should also be mindful of incorporating perspectives from other allied health professions, including nursing and public health (the latter of which has been notably more active in this space). See for example:

3.

Montero-Pau J, Álvaro N, Gavidia V, Mayoral O. Development of Environmental Health Competencies through Compulsory Education. A Polyhedral Approach Based on the SDGs. Sustainability. 2020 Apr 16;12(8):3215.

4.

Maxwell J, Blashki G. Teaching about Climate Change in Medical Education: An Opportunity. Journal of Public Health Research. 2016 Apr 26;5(1):jphr.2016.673.

5.

Leffers J, Levy RM, Nicholas PK, Sweeney CF. Mandate for the Nursing Profession to Address Climate Change Through Nursing Education: Climate Change Nursing Education. Journal of Nursing Scholarship. 2017 Nov;49(6):679–87.

6.

Lomazzi M. A Global Charter for the Public’s Health—the public health system: role, functions, competencies and education requirements*. Eur J Public Health. 2016 Apr;26(2):210–2.

7.

Jagals P, Ebi K. Core Competencies for Health Workers to Deal with Climate and Environmental Change. IJERPH. 2021 Apr 7;18(8):3849.

8.

Czabanowska K, Kuhlmann E. Public health competences through the lens of the COVID‐19 pandemic: what matters for health workforce preparedness for global health emergencies. Int J Health Plann Mgmt. 2021 May;36(S1):14–9.

9.

Bell EJ. Climate change: what competencies and which medical education and training approaches? BMC Med Educ. 2010 Dec;10(1):31.

10.

Ansari W, Stibbe A. Public Health and the Environment: What Skills for Sustainability Literacy – And Why? Sustainability. 2009 Aug 6;1(3):425–40.

1.

Bevan J, Blyth R, Russell B, Holtgrewe L, Cheung AHC, Austin I, et al. Planetary health and sustainability teaching in UK medical education: A review of medical school curricula. Medical Teacher. 2022 Dec 12;0(0):1–10.

1.

Burch H, Watson B, Simpson G, Beaton LJ, Maxwell J, Winkel K. Mapping climate change and health into the medical curriculum: co-development of a “planetary health – organ system map” for graduate medical education [Internet]. medRxiv; 2021 [cited 2023 Apr 3]. p. 2021.11.23.21265688. Available from: https://www.medrxiv.org/content/10.1101/2021.11.23.21265688v1

2.

Colbert CY, French JC, Brateanu A, Pacheco SE, Khatri SB, Sapatnekar S, et al. An Examination of the Intersection of Climate Change, the Physician Specialty Workforce, and Graduate Medical Education in the U.S. Teaching and Learning in Medicine. 2022 May 27;34(3):329–40.

3.

Hansen M, Rohn S, Moglan E, Sutton W, Olagunju AT. Promoting climate change issues in medical education: Lessons from a student-driven advocacy project in a Canadian Medical school. The Journal of Climate Change and Health. 2021 Aug 1;3:100026.

4.

Hess JJ, Heilpern KL, Davis TE, Frumkin H. Climate Change and Emergency Medicine: Impacts and Opportunities. Academic Emergency Medicine. 2009;16(8):782–94.

5.

Lapaige V, Essiembre H. Innoversity in knowledge-for-action and adaptation to climate change: the first steps of an “evidence-based climatic health” transfrontier training program. Adv Med Educ Pract. 2010;1:89–105.

6.

Létourneau S, Roshan A, Kitching GT, Robson J, Walker C, Xu C, et al. Climate change and health in medical school curricula: A national survey of medical students’ experiences, attitudes and interests. The Journal of Climate Change and Health. 2023 May 1;11:100226.

8.

McLean M, Behrens G, Chase H, El Omrani O, Hackett F, Hampshire K, et al. The Medical Education Planetary Health Journey: Advancing the Agenda in the Health Professions Requires Eco-Ethical Leadership and Inclusive Collaboration. Challenges. 2022 Dec;13(2):62.

10.

Nordrum OL, Kirk A, Lee SA, Haley K, Killilea D, Khalid I, et al. Planetary health education in medical curricula in the Republic of Ireland. Medical Teacher. 2022 Nov 2;44(11):1237–43.

11.

Omrani OE, Dafallah A, Paniello Castillo B, Amaro BQRC, Taneja S, Amzil M, et al. Envisioning planetary health in every medical curriculum: An international medical student organization’s perspective. Medical Teacher. 2020 Oct 2;42(10):1107–11.

12.

Oudbier J, Sperna Weiland NH, Boerboom T, Ravesloot JH, Peerdeman S, Suurmond J. An evidence-based roadmap to integrate planetary health education into the medical curriculum. Medical Teacher. 2023 Mar 4;45(3):328–32.

13.

14.

Wheat S, Chekuri B, Sorensen C, Rochford R, Lemery J. Creating climate-informed physician leaders: The evolution of a physician fellowship in climate and health science policy. Front Med. 2022 Dec 20;9:1060145.

1.

ASPHER CLimate and Health Competencies for Public Health Professionals in Europe [Internet]. Available from: https://www.aspher.org/download/882/25-10-2021-final_aspher-climate-and-health-competencies-for-public-health-professionals-in-europe.pdf

2.

Patrick R, Capetola T, Townsend M, Nuttman S. Health promotion and climate change: exploring the core competencies required for action. Health Promotion International. 2012 Dec 1;27(4):475–85.

The other major issue is in terms of how the authors handle counterfactuals in their reported evaluation data. L238 - I find it a bit unfortunate that you only report on your positive results, when in fact, there are counterfactuals present. It would be valuable to explore the perceptions of those respondents with qualitative data to better understand the contextually relevant aspects of those student experiences and more importantly, understand potential roadblocks and challenges associated with incorporating this material into the curriculum, or at a minimum, to report to readers whether this is possible based on what was collected or why this occurred at all.

Minor Issues:

L119 - was your pilot lesson an example of case based learning? Can you provide more detail here? How was it evaluated

L143 - suggest recasting your use of ‘longitudinal’ throughout your paper given that this word has strong associations with approaches to continued data collection in research. I think you mean that you are embedding a climate focus across their training experience. Perhaps ‘continued and successive integration of climate into medical education’ is more descriptive?

L144- please expand upon these points - what are spacing and interleaving and why were they selected of any multitude of pedagogical concepts that could have been deployed? What was your process for arriving at these two, specifically?

L155-162 - really great that you have this more structural and community-oriented lens in your training program!

L165-178 - how was the initial integration evaluated? How did you know that it worked and what if instructors and course directors ran into road blocks? Did instructors require training to implement case based learning and how was this achieved?

Reviewer #2: This paper provides pragmatic insight on an approach to addressing climate change and health in medical education. Sharing both the process and the outcomes of these efforts is important information for other faculties, who are either currently working on this or will be soon. A number of minor revisions have been suggested below, mainly focused on strengthening/improving clarity.

Overall:

1. There are a number of terms used in the paper that are not necessarily universal (tracks, clerkship, Pathways). Please ensure that they are clearly defined and used consistently throughout

Approach and Methods:

1. Is there an overarching pedagogical approach(es) used to generally guide the curriculum (i.e. inquiry-based, integrative, etc)? If so, how was your work guided by that?

2. The paper identifies “spacing” and “interleaving” as pedagogical principles; consider defining these as tools to enhance memory and attention

3. Did you consult existing pedagogical frameworks relevant to this topic (i.e. Planetary Health Education Framework)? If not, this may be something to consider for future work.

4. Additional information on survey delivery is recommended:

o How was the survey delivered to students?

o Was being a Pathways student the only eligibility criteria for participating in the survey?

o Why only 100 responses?

o When was the survey delivered in relation to when the courses were completed?

5. Consider dividing Table 3 into a table that identifies the list of questions asked, and a figure that presents the results of the survey (placed in the “outcomes and results” section).

Outcomes and results:

1. Are there any learnings to be shared about the process of gaining status as a formal curricular theme (i.e. crucial information to build the case)?

2. Please put the information on formal curricular theme status in the context of the timeline of the work outlined in the study, so that the connection between the educational intervention and adopting a new curricular theme is easily understood

Discussio

Climate Change, Environment, and Health: The Implementation and Initial Evaluation of a Longitudinal, Integrated Curricular Theme and Novel Competency Framework at Harvard Medical School

PCLM-D-23-00235R1

Dear Dr. Basu,

We are pleased to inform you that your manuscript 'Climate Change, Environment, and Health: The Implementation and Initial Evaluation of a Longitudinal, Integrated Curricular Theme and Novel Competency Framework at Harvard Medical School' has been provisionally accepted for publication in PLOS Climate.

Before your manuscript can be formally accepted you will need to complete some formatting changes, which you will receive in a follow-up email from a member of our team. 

Please note that your manuscript will not be scheduled for publication until you have made the required changes, so a swift response is appreciated.

IMPORTANT: The editorial review process is now complete. PLOS will only permit corrections to spelling, formatting or significant scientific errors from this point onwards. Requests for major changes, or any which affect the scientific understanding of your work, will cause delays to the publication date of your manuscript.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they'll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact climate@plos.org.

Thank you again for supporting Open Access publishing; we are looking forward to publishing your work in PLOS Climate.

Best regards,

Sherilee L. Harper, PhD

Academic Editor

PLOS Climate

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Thank you for revising your submission. I agree with both of the reviewers: the authors have done an excellent job revising their article and responding to reviewer comments.

Reviewer Comments (if any, and for reference):

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Does this manuscript meet PLOS Climate’s publication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS Climate does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: My thanks to the authors for attending to the important changes outlined by reviewers. I find the current manuscript considerably improved after revision, and suitable for publication in PLOS Climate.

Reviewer #2: Thank you for your responses

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Reviewer #1: No

Reviewer #2: No

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