REFLECTIONS

Climate change: could it help develop‘adaptive expertise’?

Erica Bell • Graeme Horton • Grant Blashki • Bastian M. Seidel

Received: 20 April 2010 / Accepted: 16 August 2010 / Published online: 28 August 2010� Springer Science+Business Media B.V. 2010

Abstract Preparing health practitioners to respond to the rising burden of disease from

climate change is emerging as a priority in health workforce policy and planning. How-

ever, this issue is hardly represented in the medical education research. The rapidly

evolving wide range of direct and indirect consequences of climate change will require

health professionals to have not only broad content knowledge but also flexibility and

responsiveness to diverse regional conditions as part of complex health problem-solving

and adaptation. It is known that adaptive experts may not necessarily be quick at solving

familiar problems, but they do creatively seek to better solve novel problems. This may be

the result of an acquired approach to practice or a pathway that can be fostered by learning

environments. It is also known that building adaptive expertise in medical education

involves putting students on a learning pathway that requires them to have, first, the

motivation to innovatively problem-solve and, second, exposure to diverse content mate-

rial, meaningfully presented. Including curriculum content on the health effects of climate

change could help meet these two conditions for some students at least. A working

E. Bell (&)University Department of Rural Health, University of Tasmania,Private Bag 103 Hobart, Tasmania, VIC 7000, Australiae-mail: Erica.Bell@utas.edu.au

G. HortonSchool of Medicine and Public Health, Faculty of Health, University of Newcastle,Newcastle, NSW, Australia

G. BlashkiNossal Institute for Global Health, Melbourne Sustainable Society Institute,The University of Melbourne, Melbourne, VIC, Australia

B. M. SeidelHuon Valley Health Centre, Huonville, TAS, Australia

B. M. SeidelDiscipline of General Practice, The University of Adelaide, Adelaide, SA, Australia

B. M. SeidelDiscipline of General Practice, University of Tasmania, Tasmania, Australia

123

Adv in Health Sci Educ (2012) 17:211–224DOI 10.1007/s10459-010-9245-4

definition and illustrative competencies for adaptive expertise for climate change, as well

as examples of teaching and assessment approaches extrapolated from rural curricula, are

provided.

Keywords Climate change and health � Adaptive expertise in medical practice �Innovation in medical practice � Problem-solving in medical practice � Rural medical

education and training

Introduction

Little has been published in medical education on the subject of climate change. Yet

leading generalist journals such as BMJ and The Lancet have published suites of papers on

the subject, and taken a strong public policy position on climate change (Patz et al. 2005;

Haines and Patz 2004; McMichael et al. 2007, 2008b). For example, The Lancet has

recently published a suite of reports that aim to ‘‘accelerate political and public assent for

large cuts in greenhouse-gas emissions’’ (Horton 2009, p. 1870). These have included

denouncements of the financial crisis and climate change as ‘‘markers of massive failure in

international systems that govern the way nations and their populations interact’’ (Chan

2009, p. 1870).

It may be that the slowness of climate change to arrive in specialist medical education

journals relates to the absence of a framework for understanding how climate change might

improve medical education and training. In the absence of that framework, medical edu-

cators may have a legitimate ethical concern that, whatever their private views, they not

shape the curriculum in ways that are inappropriately ideological. Climate change is

known to be a highly contentious political issue that sharply divides liberals from con-

servatives (Kohut et al. 2008). This may be true even more now in the shadow of the failed

attempt to achieve legally binding agreements between countries at the December 2009

15th Conference of Parties (COP15) in the Framework Convention on Climate Change. In

the lead-up to the Copenhagen agreement, leaked emails were the basis of allegations of

fabrication of climate change research at the Climatic Research Unit at the University of

East Anglia, making headlines around the world as climate change skeptics seized upon the

scandal (Barley 2009). The chair of the Intergovernmental Panel on Climate Change,

Rajendra Pachauri, has publicly apologised for the erroneous claim in the Fourth

Assessment report of the Intergovernmental Panel on Climate Change that the Himalayan

ice caps would melt in 35 years (rather than 300 years) (Knight 2010). While it appears

unlikely that the substantive research for climate change is wrong, the importance of

separating climate change fact from the maelstrom of belief, politics, and self-interest has

probably never been stronger.

In this ‘‘reflections paper’’ another kind of ethical question is explored: whether

excluding climate change from the medical curriculum may have implications for how well

medical educators can develop a new generation of innovative, problem-solving health

professionals with adaptive expertise. The focus in this paper is on relationships between

the theory and evidence in two research fields: climate change and medical education. This

paper asks: ‘‘What does the climate change and health research mean for developing

‘adaptive expertise’ as part of health professionals’ education?’’ Thus, the paper explores

whether the boundaries between those two fields need to be reconsidered, not in the

interests of shaping hearts and minds towards carbon control, but rather because medical

educators are committed to quality in medical education. As such this is an ideas paper

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exploring possibilities of knowledge translation: primarily from the climate change science

to medical education but also vice versa.

The climate change and health research

A large body of research now exists on the subject of what climate change will mean for

human health. Yet it is a relatively recent phenomenon. Between 1990 and 2010 over a

thousand papers on the subject of climate change and health were published in biomedical

and human life science journals. More than half of these papers were published between

2008 and 2010. Not only scholarly papers, but also a growing body of monographs have

been published emphasising the links between climate change and health and, to a lesser

extent, the key public health mitigation and adaptation strategies needed now and in the

future (Griffiths et al. 2009; Ebi et al. 2005; McMichael et al. 2003; Martens and

McMichael 2002). This body of evidence is summarised in the reports of the Intergov-

ernmental Panel on Climate Change (MacCracken 2008) and includes an emerging body of

applied research, such as the work of the United Nations (United Nations Framework

Convention for Climate Change 2006) and the World Health Organisation (EuroHEAT

website 2008) and ongoing work for the Global Environmental Change and Human Health

Project (http://www.essp.org).

In May 2009 the Lancet published a watershed paper with the University College

London Institute for Global Health Commission. This suggests that climate change rep-

resents the biggest potential threat to human health in the twenty-first century (Costello

et al. 2009). The effects of climate change are already being felt: conservative estimates

suggest that, in the year 2000 alone, climate change caused the loss of 166,000 lives and

5.5 million ‘disability-adjusted life years’ (or time lived with disability and time lost due to

premature mortality) mostly in developing countries (McMichael et al. 2004). A recent

report of the United Nation’s Global Humanitarian Forum estimated that every year cli-

mate change now leaves over 300,000 people dead and 325 million people seriously

affected. The report also estimates that four billion people are vulnerable and 500 million

people are at extreme risk (Global Humanitarian Forum 2009). Climate change is likely to

interact with socio economic disadvantage to affect the health outcomes of climate-vul-

nerable groups, particularly those in climate change ‘hotspots’: older citizens, children,

people with chronic conditions, the socioeconomically disadvantaged, as well as farmers

and others who earn their living directly off the land (Costello et al. 2009; Patz et al. 2005).

Rising temperatures and extreme weather events (drought, bushfires, hurricanes, floods)

are expected to bring a host of direct and indirect effects from deaths to injuries to food and

water supply problems to population displacement from sea level rise and coastal inun-

dation. The indirect effects of global warming include a host of waterborne diseases such

as cholera, insect-borne diseases such as malaria, West Nile virus and tick-borne

encephalitis, as well as conditions linked to air quality such as asthma (Haile 2005;

Costello et al. 2009; McMichael et al. 2003; Menne and Ebi 2006; Menne et al. 2008;

Campbell et al. 2008; Jackson and Shields 2008; MacCracken 2008; Schmidhuber and

Tubiello 2007; McMichael et al. 2006; Greer et al. 2008; Bell 2009; Global Humanitarian

Forum 2009). Thus, climate-sensitive vulnerability has been described in terms of a wide

range of individual, community and geographical factors. At the individual level, for

example, the poor are likely to be more vulnerable to such effects as malaria outbreaks. At

the community level, local disease vector distribution and control programs play a role. At

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the geographical level, populations bordering existing distributions of vector-borne dis-

eases are likely to be affected by shifts in distribution (Woodward and Scheraga 2003).

Despite this body of research including present day impacts, some remain convinced

that climate change is not a health issue that today’s graduates will face in the developed

world—that only those who graduate 50 years from now will face these impacts. In fact,

the scholarly literature on the health effects of climate change has been largely focussed on

the present and future effects in the developed world where most of the health impact

studies and risk assessments of climate change have been conducted (McMichael et al.

2008a; Turk et al. 2010; Seguin 2008). Although it is likely that, generally speaking,

wealthier nations will be better off in a climate-changing world than poorer nations, the

climate change research suggests many of the foregoing health effects will be felt in

wealthier nations too, particularly among the poor (Costello et al. 2009; McMichael et al.

2008b). For example, while adaptive capacity in Canada is generally relatively high,

assessments in that country suggest considerable variation between regions and across

populations in terms of present and future likely health effects. In Canada and other

developed nations, the health of resource-dependent and Aboriginal communities is

presently particularly vulnerable to climate change as is the health of poorer urban resi-

dents and those with pre-existing health conditions. Such groups are often more vulnerable

to food and water supply problems, heat waves and smog episodes, as well as the spread of

vector-borne diseases and other indirect effects of climate change (Lemmen et al. 2007). In

the developed world it is likely that climate change has contributed to some extent to the

following:

• the death of 70,000 people in the European heatwaves of 2003 (Costello et al. 2009;

Robine et al. 2008);

• the death of 173 people and the injury and/or traumatisation of thousands more in rural

Australian communities in the catastrophic February 2009 bushfires linked to drying of

the Australian continent (Teague et al. 2009);

• reduced rainfall in Europe, southern USA, and Australia that is increasing the numbers

of people who are suffering from the mental health effects of water supply problems

and prolonged drought (Costello et al. 2009; McMichael et al. 2008b; Arnell 2004);

• increased precipitation and flooding which is also leading to a wide range of health

effects; the Wisconsin USA flood which led to 400,000 cases of cryptosporidiosis and

100 deaths in 1993 offers a precautionary example for many developed countries

(Chivian and Bernstein 2008; Costello et al. 2009);

• rising numbers of extreme weather disasters which are also affecting many in relatively

wealthy nations—standing at less than two a year in 1950 and more than six a year in

2007 (Costello et al. 2009; Munich Re 2008)—as hurricane Katrina showed,

particularly among those who are socio-economically disadvantaged;

• rising food prices linked to climate change which are increasing the numbers of people

who are urban-based and food insecure (Costello et al. 2009).

Thus, developed nations are far from immune to the fact that the twelve warmest years

on record have occurred in the last 13 years (Costello et al. 2009; Solomon et al. 2007).

There are two main conclusions about health arising from the large body of research on

climate change. The first is that it is certain that many vulnerable populations, including in

the developed world, are now experiencing major effects of climate change (however

understood). The second is that it is very likely that unless carbon emissions are reduced

the world faces the catastrophic environmental effects of global warming which are likely

to have disastrous effects on human health, including in the developed world, particularly

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among the poor. Yet the argument underpinning this paper—that some kinds of content on

climate change should be included in the medical curriculum because this content can help

create adaptive experts in some (but perhaps not all) students—does not rely on any belief

that climate change is caused by human activity or that the world faces catastrophe if

carbon emissions are not reduced. It does require some level of acceptance that climate-

induced effects on human health are occurring now and likely to occur in the future in the

developed world to the extent that medical practitioners in climate-affected regions will

also have to deal with these effects. It does rely on a conservative interpretation of ‘the

precautionary principle’: that some considered inclusion of the health effects of climate

change in the medical curriculum is indicated because there are very likely benefits of

acting to help ensure medical professionals are well-prepared for climate change and very

likely costs of inaction. In making the argument for the value of climate change content to

building adaptive expertise this paper suggests that there are also likely benefits to the

capacity of medical education itself to deliver on one of its fundamental goals.

The many complexities of climate change science and the politics that surround it

should not distract medical educators from the task of conservatively including some

climate change content for some students suggested by this evidence-based precautionary

principle. It is true that many smaller scale integrated regional-level assessments and

predictions (as opposed to country or global predictions) are yet to be undertaken, making

it difficult for medical educators to see the relevance of climate change to practice in their

own regions. It is also arguably true that some predictions of the health effects of climate

change have been overstated, as in the case of malaria where epidemiological modelling

has not accounted for the mitigating effects of health services, especially in the developed

world (Ledford 2010; Gething et al. 2010). Further, it is expected that some regions might

actually benefit from global warming if warming is limited to below a 2 degree threshold.

However, it is already known that temperatures are likely to exceed this threshold above

which almost everyone will lose (Costello et al. 2009). In the context of this evidence, it

appears legitimate to ask what is the evidence base for excluding climate change content as

one kind of approach to understanding the wider environmental determinants of health.

If climate change and health is a relatively recent phenomenon in the scholarly research,

it has also been correspondingly slow to arrive in healthcare policy and planning. At the

May 2008 61st World Health Assembly, health ministers united to publish an important

resolution that called for a wide range of actions, including building the capacity of public

health leaders to respond to the health effects of climate change (WHO May 24 2008).

While at local, state, and national levels many government agencies have been developing

policy frameworks and adaptation plans for climate change, these are only just beginning

to include health (Fussel 2008; Balbus et al. 2008).

Climate change has also been slow to arrive in health workforce development. A

number of recent national and international policy documents, including Australia’s 2008

Human Health and Climate Change—National Adaptation Plan (McMichael et al. 2008a),

as well as scholarly studies of public health climate-change readiness, call for better

education and training for health professionals (Jackson and Shields 2008; Frumkin et al.

2008; Kovats et al. 2003; Fussel 2008; Menne and Ebi 2006; Menne et al. 2008; Ontario

College of Family Physicians 2008). The existing small body of journal publications on

climate change in primary health care education and training does not yet provide

empirically validated models for doing so (Blashki 2008; Blashki et al. 2007; Bell 2009,

2010; Green et al. 2009).

The World Medical Association has recently developed a comprehensive statement—

Declaration of Delhi on Health and Climate Change—which was adopted in October

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2009. This emphasises ‘education and capacity building’ across all the health professions.

Box 1 gives the key recommendations of that report.

However, the connections between climate change and medical education are at this

stage largely unexplored.

A facility for adaptation to climate change

A keynote in the climate change literature is the importance of adaptive practices forresponding to climate change. The adaptation literature for climate change emphasises an

idea of adaptive health services, communities and societies that change their practices and

‘‘ways of doing business’’, developing adaptive strategies over time, for example, in

response to drought (Walker 2009). Yet there is a dearth of case studies and practical ‘‘how

to’’ papers shedding light on the nature of adaptation to climate change, and the fit between

how adaptation is conceptualised in the literature and what it means ‘‘on the ground’’ in

real communities.

Notwithstanding, adaptation to climate change is conceptualised in terms of the

robustness and resilience of societies to manage change across space and time and at the

multiple levels of climate-vulnerability (Barnett and Adger 2007; Walker 2009; Woodward

and Scheraga 2003). The climate change literature distinguishes between the nature of

different kinds of events, from single catastrophic events such as bushfires to long insidious

events such as drought, in understanding the nature of adaptation and resilience. Adaptation

has a temporal nature: there can be (interrelated) short-term and long-term adaptive strat-

egies. Over the shorter term, adaptation is oriented towards management of catastrophic

events. Over the longer term, adaptation is oriented towards sustainability through inte-

grated community-building approaches that foster resilience (Walker 2009). This resilience

can be seen in a community’s ability to use intersectoral partnerships to marshall resources

and structures for recovery and rebuilding after catastrophic events (Walker 2009).

The climate change literature also conceptualises innovation for adaptation to climatechange in terms of the cultural attitudes and motivations that are the pre-conditions for this

innovation. For example, the idea of primary health care as having a ‘‘mandate’’ to work

with communities to develop adaptation strategies emerges as an important motivating

concept in this literature (Walker 2009). Adaptation is also therefore about a willingness to

‘‘stand up and be counted’’ as part of a commitment to the collective good.

But precisely how might a facility for adaptation to climate change at the health

practitioner level be defined?

The foregoing discussion suggested that the rapidly evolving wide range of direct and

indirect consequences of climate change will require health professionals to have not only

Box 1 2009 Declaration of Delhi on health and climate change workforce recommendations

3.8 Encourage recruitment of physicians for work in public health and all roles in emergency planningand response to extreme climate change, including the training of other physicians

3.9 Urge colleges and universities to develop locally appropriate continuing medical and public healtheducation on the clinical signs, diagnosis and treatment of new diseases that are introduced intocommunities as a result of climate change, and on the management of long-term anxiety and depressionthat often accompany experiences of disasters

3.10 Urge governments to provide training for climate-change-related emergency response to physicians,particularly those living in relatively isolated regions (WMA 2009)

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broad content knowledge but also flexibility and responsiveness to diverse regional con-

ditions as part of complex health problem-solving and adaptation. The regional uncertainty

and unpredictability of climate change is likely to place a considerable impost on the

adaptive capabilities of health professionals (Bell 2009).

Considered collectively, the climate change literature on health, including on adaptive

responses to climate change (Fussel 2008), suggests the preliminary working definition of

the clinical and non clinical dimensions of this adaptive expertise for climate change given

in Box 2.

Accordingly, the climate change literature raises an important question: should medical

education be ensuring that this capacity for adaptation and responsiveness to local contexts

is integrated into curriculum design, teaching and assessment? We could theorise that, as

curricula does progressively address site-specific needs related to climate change impacts,

‘‘adaptive expertise’’ will be increasingly understood in terms of these regional needs.

Adaptive expertise in medical education

‘‘Adaptation’’ is already an important construct in medical education and training research,

as well as education research more generally (Bransford et al. 2000; Bransford and Sch-

wartz 1999). It includes the ability to ‘‘innovate new solutions in response to daily

workplace challenges’’ as part of an ‘‘adaptive expertise’’ (Mylopoulos and Regehr 2009,

p. 127). Doctors and other healthcare workers need to be able to not only integrate new

knowledge, but also further develop that knowledge to continuously improve the quality of

healthcare (Mylopoulos and Regehr 2009). Adaptive expertise in medical practice is thus

an ability to acquire, integrate and use new knowledge to solve new problems in daily

practice (Norman 2005; Eva 2005; Mylopoulos and Regehr 2009). The new knowledge

that is sought is wide-ranging: it can take the form of ideas or procedural information.

What is important is that it leads to new combinations of knowledge that produce new

ways of practicing medicine. Thus adaptive expertise has been understood to be part of

innovative, higher order ‘problem-solving’ involving knowledge transfer across the dis-

ciplines (Schwartz et al. 2005).

Not surprisingly then, adaptive expertise is conceptualised as a complex multi-faceted

construct in the adaptation expertise literature. It is not one skill: the literature describes it as

a ‘‘learned skillset’’ acquired along a pathway to innovative practice that contrasts with the

pathway to ‘‘routine expertise’’ (Mylopoulos and Regehr 2009, p. 128). Taking the pathway

to routine expertise may be at the cost of reaping the benefits to be had by taking the

pathway to adaptive expertise (Mylopoulos and Regehr 2009). It seems that some experts go

Box 2 A working definition of adaptive expertise in a climate-changing world

Adaptation for climate-change involves a facility for climate-change problem-solving evident in clinical andnon clinical aspects of practice. That is, it involves a capacity to decipher and integrate ecologicalinformation to adapt existing healthcare responses for climate-influenced health challenges. Theinformation may be implicit in, for example, presenting medical conditions or it may be explicit in, forexample, regional public health reports. The information may be used to avoid, prepare for, or respond tohealth challenges linked to climate change. The responses may include adaptive clinical diagnostic,planning and intervention responses for clients affected by climate-change, emergency care responses forextreme climate events, health service development for climate-driven changes in public health needs,culturally appropriate responses for indigenous community-based challenges such as drought resilience, aswell as other professional and team-oriented responses for climate-changing regional contexts

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beyond routine competencies and demonstrate adaptive expertise in which they consistently

try to find problems and challenges that stretch the boundaries of their competency. They

may not necessarily be as quick at solving familiar problems, but they do creatively seek to

better solve novel problems. This may be the result of an acquired approach to practice or a

pathway that can be fostered by learning environments (Mylopoulos and Regehr 2007).

Adaptive expertise has been variously described as central to the kind of well-rounded

health professional needed in modern health services. Thus adaptive professionals are able

to adapt to change, to generate new knowledge as part of an engagement with complexity

and uncertainty that is directed at improvement of self and environment (Fraser and

Greenhalgh 2001). They seem to balance both the efficiency (routine-oriented) and

innovation aspects of expert practice (Varpio et al. 2009).

What is known about barriers and facilitators to acquiring adaptive expertise?

Much of the adaptive expertise literature focuses on how to put learners on the pathway

to adaptive expertise. It is known that the development of adaptive expertise relies on the

existence of certain attitudes before it can be exercised or even developed. For example,

there are indications that perceptions that learners have that they have no responsibility to

be innovative shapes the extent to which they will learn to become adaptive experts

(Mylopoulos and Regehr 2009). There are also indications students see themselves as

learners and innovation as something that can emerge after their training, in their daily

practice i.e. that they struggle to see the connection between lack of innovative problem-

solving in their learning and later ability to be innovative in practice (Mylopoulos and

Regehr 2009). Another study suggests that medical practitioners’ attitudes to innovation

are important: while those in this study did innovate in their daily practice, they do not see

how this knowledge has value beyond their own individual scope of practice (Mylopoulos

and Scardamalia 2008). There is a need to know more about what motivates adaptive

professionals to push the boundaries of routine practice and be innovative problem-solvers

(Varpio et al. 2009).

Little is also known about whether medical students feel that they have more respon-

sibility to be innovative in particular areas than in others. The literature on adaptive

expertise in medical education doesn’t necessarily tell educators how to encourage the

belief in students that they have a responsibility to be innovative problem-solvers (My-

lopoulos and Regehr 2009). Yet it is likely that real generational differences have an

important role to play in the effectiveness of medical education (Twenge 2009). There are

indications that ‘‘Generation Me’’ has a distinctive set of experiences in the world that have

shaped their supposed lower self-reliance and higher anxiety. What if the barriers to setting

students on the path to adaptive expertise were artificial ones created by a lack of

knowledge about areas where students are more likely to accept that they have a role to be

innovative problem-solvers? There are calls for medical students to be given ‘‘legitimate

experiences’’ where they can engage with innovative problem-solving (Mylopoulos and

Regehr 2009). Could medical education better develop these legitimate experiences by

drawing on evidence about how students understand their own responsibilities as change-

makers, including social responsibilities?

Willingness to be innovative is, of course, only one aspect of the challenge of devel-

oping adaptive expertise. Adaptive expertise is critical to effective clinical reasoning which

has largely been studied in terms of diagnostic reasoning—the ability to flexibly integrate

diverse information and presentations to generate diagnostic decisions. Adaptive expertise

in diagnostic reasoning is an expertise that is related to, but distinct from, the actual content

area in which the decision-making occurs (Eva 2005). Diagnostic reasoning includes

analytic reasoning involving probabilistic causal thinking as well as non analytic reasoning

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involving ‘‘pattern recognition’’ based on past experience (Eva 2005). What does this mean

for the presentation of content to students in ways that facilitate both kinds of reasoning?

Eva argues for an additive model of diagnostic reasoning in which analytic and non

analytic reasoning work in diverse and complementary ways (Eva 2005). This accords to

some extent with Norman’s findings after review of the sprawling clinical reasoning lit-

erature: that clinical reasoning expertise involves acquisition of ‘‘illness scripts, decision

trees, symptom x disease probabilities, semantic qualifiers and more (or less) basic sci-

ence’’ as well as ‘‘recognition of a similar prior example’’ (Norman 2005, p. 422). He

concluded that ‘‘clinical reasoning is a consequence of an extensive and multidimensional

knowledge base’’ (Norman 2005, p. 423). If Eva’s model is right then clinical reasoning is

an organic entity and the kinds of content presented to students for diagnosis need to be

able to develop diversity and complexity in the strategies used by them to solve diagnostic

problems (Eva 2005).

Content thus needs to be wide-ranging and diverse (a few complex cases are not optimal

and narrowness of context can be suboptimal) and mimic the mixed presentation of cases

in real life. Facilitation of lesson-drawing from new material using familiar material is

important. Multiple examples can help foster the practice of knowledge and skills in

different contexts, assisting conceptual knowledge transfer and plasticity or flexibility of

thinking (Norman 2005). Thus the challenge in part is to present new contexts for learning,

to broadly ‘‘sample’’ (Eva 2005).

However, the emphasis should be on new contexts that are designed to help students

acquire the practices of being adaptive experts: new contexts can only develop adaptive

expertise if they offer more than content to be learned (Mylopoulos and Regehr 2007).

That is, diversity of context must be meaningful for acquiring adaptive expertise.

In summary, adaptive expertise in the medical education literature is not a singular

process that can be taught as such, but rather a dynamic multidimensional construct.

Building adaptive expertise seems to involve putting students on a learning pathway that

requires them to have, first, the motivation to innovatively problem-solve and, second,

exposure to diverse content material, meaningfully presented. Could learning about the

health effects of climate change help meet these two conditions?

Application of climate change and health research to medical education

What if climate change could present to students as a domain in which they have a

responsibility to be innovative? Could climate change help educators put students on the

pathway to adaptive expertise? There are indications that climate change is already per-

ceived by the current generation of students as a domain in which they have a certain

responsibility. A survey of 26,718 citizens in the 27 Member States of the European Union

suggested that older respondents (aged 55?) are less likely to perceive that climate change

is a serious problem (44%) than all younger age groups (Directorate-General for Com-

munication of the European Commission 2009). Younger people are more likely to accept

that human activity is the cause of global warming. A study of 1,502 Americans found that

more than half of people under age 30 (54%) believe that the earth is warming mostly

because of human activity compared with only 44% of those in the 50–64 age group.

The overwhelming majority of those who believe that global warming is caused by

human activity (82%) say that they believe that human agency can also reduce its

effects, and the majority (54%) indicate a willingness to themselves make major sacrifices

(Kohut et al. 2008).

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This poses the question of whether medical educators are less likely than their students

to see the possibilities of climate change as a domain in which adaptive expertise can be

developed. It also raises the question of whether a willingness to take responsibility for

mitigation on the part of students might be at all related to a willingness to see climate

change as an area in which adaptive expertise could and should be developed in medical

education and training. It seems possible that the sense of personal responsibility for

climate change is sufficiently transferable among students that it could create a greater

willingness to be innovative in response to curriculum content involving climate change, at

least among some students.

Part of the challenge of applying climate change research to medical education is

translational: about developing practical frameworks for understanding the possibilities of

the climate change literature for medical education. Box 3 suggests one possible way of

conceptualising the application of the climate change literature: it offers illustrative gen-eric competencies for the adaptive medical professional in a climate-changing world. It

draws upon the characteristics that have been identified for adaptive decision-making for

climate change and health, notably by Fussel (2008), Scheraga et al. (2003) and Woodward

and Scheraga (2003). The definition of competence underpinning the table is not about

basic standards i.e. competency understood as a minimum requirement for performance.

Rather, Box 3 suggests that ideal performance that might be standard for the adaptive

expert (Brawer 2009).

Box 3 could be used as a point of departure for empirical development of more detailed

competencies and specific learning outcomes for adaptive expertise for a climate-changing

world. Scaffolded learning approaches could be used to build in novel climate change

contexts with meaningful reference to existing bio-medical and clinical knowledge. A core

content set on climate change could be presented via workshops and seminars, and

regionally contextualised problem-based or simulated learning could be used to encourage

learners to accommodate different levels of uncertainty, and to make decisions about

adaptive plans and responses through the use of diverse plausible scenarios (Fussel 2008).

Illustrative examples of such teaching and assessment approaches are given in Box 4

under each of the seven domains of the Primary Curriculum document of the Australian

College of Rural and Remote Medicine, which has a strong focus on relationships between

individual health, community and ‘‘place’’ or geography—the three domains of climate-

sensitive vulnerability identified in the work of Woodward and Scheraga (2003). Inter-

nationally, the Australian College of Rural and Remote Medicine curriculum document is

also the most detailed definition of the competencies needed by rural and remote

Box 3 Illustrative generic competencies for the adaptive medical professional in a climate-changing world

Adaptive practitioners are able to:

1. Manage complexity and uncertainty in planning for a climate-changing future, at both individual clientand healthcare system levels

2. Integrate a wide range of information, both climate-related and non climate-related, to respondeffectively to conditions with diverse causal relationships

3. Reduce climate-sensitive health risks by utilising existing knowledge about these in a particular regionand seeking to further develop this knowledge base

4. Effectively assess climate-sensitive vulnerabilities including the feasibility of different adaptationoptions and measures for controlling health risks

5. Reduce vulnerability to current climate variability through adaptive measures

6. Integrate adaptation decisions for health into existing healthcare management polices and practices

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practitioners. The broad application of this document to teaching the health effects of

climate change i.e. the broad competencies involved, has already been identified (Bell

2009, 2010). Box 4 builds on this previous work, using the Australian College of Rural and

Remote Medicine curriculum document to make specific suggestions about how adaptive

expertise for climate change might be taught across different contexts. Elements of these

approaches might be used at both the undergraduate and postgraduate levels.

Conclusion

Much of the literature on climate change and health has been shaped by a negative futures

disease scenario approach or sustainability imperative. These have not necessarily pro-

vided opportunities to reflect upon and translate the positive learnings that the climate

change research offers health workforce education and training.

In a context in which the challenge of translating the climate change literature will not

be addressed simply by more research on the health effects of climate change, this

reflections paper has explored some of the knowns and unknowns of that research. It has

suggested that what is known is weighty enough to support the view that medical educators

should consider including some kinds of climate change content in the medical curricula

now. It has also suggested that this is important because medical educators have a role

ensuring that graduates are flexible, problem-solving, adaptive health professionals able to

Box 4 Illustrative examples of teaching and assessment approaches for preparing adaptive medicalprofessionals

1. ‘Core clinical knowledge and skills for generalist practice’: interactive problem-based learningmodules could be used to develop diagnostic reasoning utilising information about climate-sensitivehealth vulnerabilities to vector borne diseases such as tick-borne encephalitis or Dengue fever

2. ‘Extended clinical practice’: simulated team situations could be used to develop leadership andparticipation in team-based approaches to climate-sensitive health risks, such as gastroenteritisoutbreaks

3. ‘Emergency care in generalist practice’: simulated team learning situations could be used to developparticipation in climate-influenced disaster planning and implementation of disaster plans, as well aspost-incident analysis and debriefing for events such as bushfires

4. ‘Population health in generalist practice’: online tutorials and case-based discussion groups could beused to develop skills in integrating evidence-based prevention, early detection and related healthmaintenance measures, into practice at the health systems level in, for example, responding toheatwaves

5. ‘Aboriginal and Torres Strait Islander health in generalist practice’: meetings with members ofindigenous communities followed by reflective journal write-ups could be used to build skills inworking in a cross-cultural team using local protocols for referral and involvement of indigenous healthworkers in climate sensitive situations, such as drought and coastal inundation, affecting communityresilience and well-being

6. ‘Professional, legal and ethical practice in generalist practice’: online tutorials could build skills inusing communication technology to network and exchange information with other professionals aboutclimate-sensitive health conditions, as well as developing approaches to self-directed learning aboutclimate-sensitive vulnerabilities

7. ‘Rural and remote context in generalist practice’: investigative projects could be used to buildresourcefulness in obtaining information about climate-sensitive health vulnerabilities relevant to aspecific region, as well as health adaptation measures and controls viable for that region, in meetingchallenges such as asthma

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make a difference to the capacity of vulnerable populations to themselves adapt to climate

change, including through a wide range of preventative health measures. It has further

explored why and how this adaptive expertise might be taught to students using curriculum

material that takes a focus on the health effects of climate change. There is some evidence

to suggest that this curriculum material could help put students on the learning pathway to

adaptive expertise by satisfying two conditions for that expertise: the motivation to

innovatively problem-solve and exposure to diverse content material, meaningfully pre-

sented. The value of climate change content for student motivation appears to lie in the

way students perceive climate change to be an area where they have an important social

and personal responsibility. The value of climate change content for exposing students to

diverse contexts, meaningfully presented, lies in the way that it applies to so many domains

of curricula, particularly in rural and remote medicine. This paper has used the example of

rural medical curricula to suggest that climate change and health is a theme that can be

used to form connections across otherwise vertical curricula. As such, it has real potential

for building that extensive, multidimensional knowledge base that is the foundation of

clinical reasoning (Norman 2005). Finally, there may be an ethical argument that students’

generational commitment to the collective good in a climate-changing world needs to be

not only recognised but also mobilised within medical education to make them the best

practitioners they can be.

Acknowledgments This work was funded by the University Department of Rural Health (UDRH) at theUniversity of Tasmania under an operating grant from the Commonwealth Department of Health andAgeing.

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