Adapting the Planetary Health Report Card for Graduate Medical Training Programs

Introduction

Leading international medical organizations recognize human-caused climate change as an urgent threat to public health and social justice.^1-4 This concern has given rise to the field of “planetary health,” whose proponents study and advocate for environmental stewardship to protect human health and equity.⁵ In 2019, medical students created a metric-based tool called the Planetary Health Report Card (PHRC) to evaluate and inspire climate action in undergraduate medical education (UME) institutions.^6,7 Originally piloted at 12 US and Canadian medical schools, the PHRC has now been used at 151 health professional schools in 18 countries across North America, Asia, Africa, Europe, and Oceania, as well as adapted for disciplines including nursing, occupational therapy, physiotherapy, pharmacy and veterinary medicine.^6,7

The PHRC evaluates medical schools across 5 domains: (1) curriculum; (2) research; (3) community outreach and advocacy; (4) support for student-led planetary health initiatives; and (5) campus sustainability.^6,8,9 Medical students use PHRC findings to drive institutional change.^6,10,11 For example, students have successfully advocated for new curricular requirements, a sustainability office’s creation, and the appointment of student representatives to institutional decision-making bodies.⁶ Graduate medical education (GME) and UME differ in their curriculum structure, specialty-specific content, clinical duties, employment status, and variation between academic and community settings. Therefore, the PHRC requires adaptation to GME.

Efforts to incorporate planetary health and sustainability into GME are nascent and growing.^8,12,13 This project aims to adapt the PHRC to GME, allowing trainees to advocate for climate action within their institutions using a standardized tool with a successful track record. This article presents preliminary findings from this effort.

Methods

Our research team includes a contributing author (S.S.), a cofounder (K.H.) and current leaders of the UME PHRC (T.D., I.W.), and a GME program leader with experience in the Delphi Panel method (A.B.).

In 2022, to develop domains and metrics for the GME PHRC, S.S, K.H., T.D., and I.W. met and reviewed the 2022 UME PHRC, discussing differences between UME and GME relevant to the tool.¹⁴ Due to major differences in curriculum requirements, S.S. reviewed literature on GME planetary health curricula and edited the existing curriculum metrics accordingly.^12,13,15 We also saw an opportunity to shift the sustainability domain’s focus from UME campuses to GME-affiliated health systems. Therefore, S.S. reviewed literature on health care sustainability best practices and edited existing sustainability metrics accordingly.^16-19 Proposed metrics in other domains matched the 2022 UME PHRC metrics, with the word “student” changed to “trainee,” and “school” to “program” or “institution.”

To determine expert consensus on proposed GME PHRC metrics, we chose a modified Delphi Panel method.²⁰ This method is suited to developing and measuring consensus in areas with limited preexisting literature or practice. It allows participants to review their peers’ anonymized responses from prior survey rounds to inform their own choices in subsequent rounds. We drew methodological inspiration from work to develop anti-racism metrics for GME.^21,22

S.S and A.B. developed the first round survey instrument (see online supplementary data) using REDCap (Vanderbilt University) software hosted at Children’s National Hospital.^23,24 REDCap is a secure web-based platform designed to support validated data capture, export, and auditing in research.

In 2023, we recruited participants via purposive and snowball sampling. We recruited individually and via online fora of organizations, including the PHRC, Medical Students for a Sustainable Future, Health Care Without Harm Physician Network, and American Academy of Pediatrics Chapter Climate Advocates.^6,25-27 Participants were eligible if they attested to (1) being current trainees in residency, fellowship, or the final clinical year of medical school, or current GME faculty or program leadership; and (2) having “experience, expertise, and/or meaningful commitment to action on planetary health, climate change, health care sustainability, and health equity” (see Intake Form in online supplementary data).

We asked participants to score each domain using a 4-point modified Likert scale, indicating if they “strongly agree,” “agree,” “disagree,” or “strongly disagree” that each domain “is a key sign of commitment to planetary health, sustainability, and environmental justice for academic graduate medical training institutions.” On the same scale, we asked participants whether each proposed metric “is an accurate way for graduate medical training institutions to assess their progress” in each domain. We set greater than 70% as the a priori agreement level required to merit inclusion of a domain or metric in the GME PHRC. We invited open-ended comments on all domains and metrics and noted when multiple respondents wrote similar comments. We completed first-round data collection and plan for at least one more round.

The Children’s National Institutional Review Board deemed the study “not human subjects research.”

Results

We recruited 45 eligible participants, of whom 20 (44%) completed a first round survey. Participants came from the United States, Canada, and the United Kingdom. They included trainees and faculty in various medical and surgical specialties. The Table summarizes participant demographics (see online supplementary data for a map of participants from all US census regions).²⁸

Table Demographic Summary of First Round Survey Participants

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The Box shows the domains and metrics proposed in the survey. Agreement exceeded 70% on all metrics in the curriculum, trainee support, and sustainability domains, with a range of 75% to 100% of participants indicating they agree or strongly agree with metric accuracy. The research and community outreach domains each had one metric fall below the agreement threshold.

Participants gave rich open-ended feedback on metric wording, scoring, and relevance to GME. Multiple participants recommended adding metrics focused on climate resilience and preparedness in health systems and surrounding communities. Others stated that programs offering faculty development and paid protected time should score higher than programs that allow GME trainees to lead planetary health initiatives without compensation. Participants expressed differing views on program and institutional obligations to offer research experiences and community-facing education.

Discussion

Our study finds that trainees and faculty with knowledge of and commitment to planetary health agree that adapted PHRC metrics can accurately evaluate GME programs’ and institutions’ commitment to planetary health, sustainability, and environmental justice. Consensus was strongest on metrics evaluating curriculum, support for trainee-led initiatives, and health care sustainability.

The only domains with metrics falling below the agreement threshold were research and community outreach. The second round survey will allow participants to review each other’s compiled responses, so perspectives may evolve.

Following this study, we plan to pilot the GME PHRC with trainees across specialties and institutions. The pilot group will create a scoring rubric based on open-ended comments from the Delphi Panel. Because sponsoring institutions may house multiple GME programs, we anticipate cross-specialty collaboration within institutions, and scoring that recognizes both program-level and institution-wide initiatives.

This study has multiple limitations. While study team members reviewed and tested the survey instruments, no psychometric review was completed. Our respondents came mainly from urban, academic settings, which may limit applicability to rural and community-based programs. Furthermore, we know little about why our nonrespondents chose not to complete the survey and whether their participation would have changed outcomes.

Health systems increasingly recognize their duty to limit environmental harm and to prepare trainees to prevent, diagnose, and treat the diseases of a changing planet.^16,17,29 We believe the GME PHRC will be a valuable tool in these efforts, promoting standardized comparison and cross-pollination between GME programs.

Conclusions

In the first round of a modified Delphi Panel survey, trainees and faculty in GME programs agree that metrics adapted from the PHRC are relevant to evaluating GME programs and institutions on planetary health, sustainability, and environmental justice.