Strategies for Clinical Discussions About Climate Change
Authors: Emily Senay, Mona Sarfaty, Mary B. Rice
Journal: Annals of Internal Medicine (2020)

Ideas and OpinionsMarch 2021Strategies for Clinical Discussions About Climate ChangeFREEEmily Senay, MD, MPH, Mona Sarfaty, MD, MPH, and Mary B. Rice, MD, MPHEmily Senay, MD, MPHWorld Trade Center Health Program Clinical Center of Excellence, Selikoff Centers for Occupational Health, Icahn School of Medicine at Mount Sinai, New York, New York (E.S.), Mona Sarfaty, MD, MPHMedical Society Consortium on Climate and Health, Center for Climate Change Communication, George Mason University, Chevy Chase, Maryland (M.S.), and Mary B. Rice, MD, MPHand Beth Israel Deaconess Medical Center, Boston, Massachusetts (M.B.R.).Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-6443 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Misinformation has contributed substantially to the failed U.S. response to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic (1). Countering large-scale misinformation about health risks typically falls to public health leaders, but the political divide has weakened their persuasive power. Consequently, many people doubt expert advice and question risk. To date, coronavirus disease 2019 (COVID-19) has killed 300 000 Americans—with no end in sight. The pandemic, however, is not the only serious public health threat we face in 2020. The warmest year on record so far, 2020 is confirming predictions about the pace of climate change, which has been called the greatest threat to public health of the 21st century (2). These 2 crises share similar challenges: Both are the subject of campaigns to doubt the science; both cause significant morbidity and mortality; and both require swift, collective, and sustained action to avert worst-case scenarios. The pandemic provides a clear lesson for clinicians. As the climate crisis worsens, public health messaging alone will not be enough to help patients make the link among emissions, climate instability, and their own health. Clinicians have a clear role to play in countering misinformation, especially when the stakes are so high. The stakes for human well-being in a rapidly changing climate could not be higher, and the time to deliver the truth is now.Clinicians retain their reputation as trusted sources of information (3) and are uniquely positioned to counter misinformation during clinical encounters. Physicians have an ethical duty to provide patients with evidence-based information to guide educated choices about their health (4). This duty holds even if that information has been distorted, cast in doubt, or politicized. In 2016, the American College of Physicians (ACP), joining 28 other medical societies under the umbrella of the Medical Society Consortium on Climate and Health, called on physicians to objectively inform patients, communities, and all stakeholders within their sphere of influence about climate health threats, to help depoliticize the issue (5). In physician surveys, 80% to 90% acknowledge the reality of manmade climate change, and the majority of respondents believe it is relevant to the patients' health. Limited time, low reimbursement, and fear of igniting political resentment are cited as reasons for reluctance to discuss climate during clinical encounters. Yet, the most common reason for hesitation is lack of knowledge about how to discuss climate change with their patients (5). Incorporating brief educational messages or applying conversational techniques often used to motivate behavior change are useful strategies that can overcome these concerns and enable effective communication on important public health topics.The goal of patient-centered communication is to convey medical information while addressing the patients' concerns and expectations to reach a shared concept of the best path forward. Demonstrating empathy, a collaborative spirit, and avoiding judgment improves patients' understanding of medical information, adherence to advice, overall satisfaction, and even recovery (6). In fact, parents concerned about vaccine safety credit a warm rapport with a pediatrician as the most important factor in deciding to immunize their children (7). Clinicians routinely counsel patients on drivers of disease (for example, that poor diet causes chronic disease) and should also educate patients about health risks related to more controversial topics (8). Physicians can build into clinical discussions brief educational messages relevant to the patient's medical needs and goals and delivered nonconfrontationally with compassion. Such messaging can be as simple as, "Climate change is causing allergy season to start earlier and making plants produce more pollen. This may explain why your allergies are acting up now." Examples of scripts to facilitate climate messaging are depicted in the Table.Table. Clinical Scenarios for Climate MessagingMotivational interviewing techniques can help match the message to the patient and steer the conversation away from controversy. These techniques respect the patient's decision-making autonomy; avoid directives,which are frequently met with resistance; and can help counter misinformation by amplifying the ambivalence inherent in controversial topics (8). These conversations can begin by explaining the role climate plays in the patient's health and asking permission to discuss the topic. For example, "You mentioned that your breathing gets worse on hot days. We know the climate is warming, and this combined with air pollution and ozone makes it hard for some to breathe. Would it be all right if we discussed this, and I shared some information that I think you might find helpful?" When strong doubts are expressed, roll with it, resist the impulse to convince, confirm respect for their views, and conclude with your commitment to their health: "I hear you. I know climate change is controversial. I am always here if you want to learn more about how climate can harm health. But today let's focus on things we can do to protect your breathing when it gets hot." If it is comfortable to explore, open-ended questioning can help patients recognize discrepancies on their own. For instance, patients may acknowledge hotter days or earlier spring blooms, but do not link these to human behavior.Evidence suggests that framing messages with an emphasis on benefits to the patient, highlighting how they align with their goals and values and are consistent with in-group norms, tends to be more persuasive (9). Further, handing patients accurate, clear, and credibly sourced material increases satisfaction and is more effective than leaving material freely available (10). Conveying concrete actions that patients can take to protect their health reduces the anxiety and dread related to overwhelming threats like the pandemic and climate change.The catastrophic consequences of pandemic misinformation are a dry run for climate change. Clinicians can help counter misinformation during routine visits by using simple messages that educate and empower patients. Adapting additional insights from the sociobehavioral sciences could also better guide clinical encounters. Information inoculation, or "prebunking," strategies expose people to misinformation techniques and provide credibly sourced facts that create "psychological" immunity to fake news (9). Now more than ever, physicians must deliver the truth and embrace their duty to warn, educate, and equip patients with information that can protect them, their families, and communities—and humanity—from the existential threat of climate change.References1. Chappell B. U.N. chief targets 'dangerous epidemic of misinformation' on coronavirus. NPR. 14 April 2020. Google Scholar2. U.S. Global Change Research Program. The Impacts of Climate Change on Human Health in the United States: A Scientific Assessment. U.S. Global Change Research Program; 2016. Google Scholar3. Kelley JM, Kraft-Todd G, Schapira L, et al. The influence of the patient-clinician relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials. PLoS One. 2014;9:e94207. [PMID: 24718585] doi:10.1371/journal.pone.0094207 CrossrefMedlineGoogle Scholar4. AMA Council on Ethical and Judicial Affairs. AMA Code of Medical Ethics' opinions on informing patients. AMA J Ethics. 2012. doi:10.1001/virtualmentor.2012.14.7.coet1-1207 Google Scholar5. Crowley RA; Health and Public Policy Committee of the American College of Physicians. Climate change and health: a position paper of the American College of Physicians. Ann Intern Med. 2016;164:608-10. [PMID: 27089232] doi:10.7326/M15-2766 LinkGoogle Scholar6. Ha JF, Longnecker N. Doctor-patient communication: a review. Ochsner J. 2010;10:38-43. [PMID: 21603354] MedlineGoogle Scholar7. Edwards KM, Hackell JM; Committee on Infectious Diseases, the Committee on Practice and Ambulatory Medicine. Countering vaccine hesitancy. Pediatrics. 2016;138. [PMID: 27573088] doi:10.1542/peds.2016-2146 CrossrefGoogle Scholar8. Rubak S, Sandbaek A, Lauritzen T, et al. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract. 2005;55:305-12. [PMID: 15826439] MedlineGoogle Scholar9. Bavel JJV, Baicker K, Boggio PS, et al. Using social and behavioural science to support COVID-19 pandemic response. Nat Hum Behav. 2020;4:460-471. [PMID: 32355299] doi:10.1038/s41562-020-0884-z CrossrefMedlineGoogle Scholar10. Streiffer RH, Nagle JP. Patient education in our offices. J Fam Pract. 2000;49:327-8. [PMID: 10778838] MedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Richard I. Horowitz, MDMedical director, Hudson Valley Healing Arts Center; Member, HHS Babesia and Tick-borne Pathogens subcommittee 202019 December 2020 Climate Change and Global Health: Going Beyond the Tip of the Iceberg The recent ACP article, 'Strategies for Clinical Discussions About Climate Change' by Senay et al. is an excellent beginning to a complex subject. As health care providers, we are tasked with protecting our patients based on the best available science. The consensus of climate scientists from around the globe is that climate change represents an existential threat to humanity's survival and global health [1], yet there are other dangers not highlighted in the article that deserve comment. The changes in the climate have already been linked to increased morbidity and mortality, including temperature-related illness and death. This includes heat stroke due to extreme weather effects; increased respiratory illness like asthma and COPD due to the effects of air pollution; increasing rates of autoimmune diseases, cancer, cardiovascular and neurologic complications including dementia, autism, and pregnancy complications due to environmental chemical exposure, small particle pollution and toxic chemical exposure from wildfires [2].Tropical cyclones, hurricanes and storms surges in the past few years have also resulted in water damaged buildings and toxic mold overgrowth with insidious health effects. Mold toxicity has been linked to chronic fatigue, headaches and fungal sinusitis, increased allergies, exacerbation of asthma, increased respiratory infections as well as kidney, liver and lung disease, immune suppression, and cancer [3]. There is also the risk of water and food-related diseases from lack of proper sanitation with increased outbreaks of infectious diarrhea; as well as an increase in the range and distribution of vector borne diseases, including mosquito borne illness (malaria, dengue fever, Chikungunya) and tick-borne disease including Lyme disease [4]. These vector-borne outbreaks are expected to increase at higher temperatures, along with increases in water temperatures resulting in toxin-producing algae from cyanobacteria, resulting in allergic, respiratory, and gastrointestinal symptoms. Resulting food and water shortages are also expected to lead to climate refugees and population displacement [3], significantly affecting our mental health and physical health in an adverse manner over time. The people most vulnerable to these devastating climate effects will be children, the elderly, disabled individuals as well as disadvantaged racial groups. Climate injustice is inextricably linked to racial injustice. Apart from the moral imperative to appropriately remedy this major imbalance, if we do not act in a decisive manner now, based on the science in the recent IPCC report [5], we may as a global society be heralding the first phase of our planets 6th extinction. Scientific references: Butler CD. Climate Change, Health and Existential Risks to Civilization: A Comprehensive Review (1989⁻2013). Int J Environ Res Public Health. 2018;15(10):2266. Published 2018 Oct 16. doi:10.3390/ijerph15102266 Tord Kjellstrom and Haylee J. Weaver. Climate change and health: impacts, vulnerability, adaptation and mitigation. Vol. 20(1–2) 2009 NSW Public Health Bulletin Pizzorno J. Is Mold Toxicity Really a Problem for Our Patients? Part I-Respiratory Conditions. Integr Med (Encinitas). 2016;15(2):6-10. Hunter PR. Climate change and waterborne and vector-borne disease. J Appl Microbiol 2003; 94: S37–46.doi:10.1046/j.1365-2672.94.s1.5.x The International Panel on Climate Change 6th Assessment Report https://www.ipcc.ch/assessment-report/ar6/ Author, Article, and Disclosure InformationAffiliations: World Trade Center Health Program Clinical Center of Excellence, Selikoff Centers for Occupational Health, Icahn School of Medicine at Mount Sinai, New York, New York (E.S.)Medical Society Consortium on Climate and Health, Center for Climate Change Communication, George Mason University, Chevy Chase, Maryland (M.S.)and Beth Israel Deaconess Medical Center, Boston, Massachusetts (M.B.R.).Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-6443.Corresponding Author: Emily Senay, MD, MPH, Icahn School of Medicine at Mount Sinai, 17 East 102nd Street, Box 1043, New York, NY 10029-6574; e-mail, emily.[email protected]edu.Current Author Addresses: Dr. Senay: World Trade Center Health Program Clinical Center of Excellence, Selikoff Centers for Occupational Health, Division of Preventive Medicine, Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, 17 East 102nd Street, Box 1043, New York, NY 10029.Dr. Sarfaty: Medical Society Consortium on Climate and Health, Center for Climate Change Communication, George Mason University, 4501 Leland Street, Chevy Chase, MD 20815.Dr. Rice: Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Shapiro 7, Boston, MA 00215-5400.Author Contributions: Conception and design: M.B. Rice, M. Sarfaty, E. Senay.Drafting of the article: M.B. Rice, E. Senay.Critical revision for important intellectual content: M.B. Rice, M. Sarfaty, E. Senay.Final approval of the article: M.B. Rice, M. Sarfaty, E. Senay.This article was published at Annals.org on 15 December 2020. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byDaily diurnal temperature range associated with outpatient visits of acute lower respiratory infection in children: A time-series study in Guangzhou, ChinaLifestyle Medicine Interventions for Personal and Planetary Health: The Urgent Need for ActionSmall Devices, Big Problems: Addressing the Global Warming Potential of Metered-Dose InhalersHealth and Clinical Impacts of Air Pollution and Linkages with Climate ChangeClimate Change: Implications for Community Mental HealthAddressing Climate-Related Health Impacts During the Patient EncounterPatients value climate change counseling provided by their pediatrician: The experience in one Wisconsin pediatric clinicDiscussing climate change and other forms of global environmental change during the clinical encounter: Exploring US physicians' perspectivesClimatizing the internal medicine residency curriculum: A practical guide for integrating the topic of climate and health into resident educationLifestyle medicine prescriptions for personal and planetary health March 2021Volume 174, Issue 3Page: 417-418KeywordsAllergy and immunologyBehaviorBreathingCOVID-19Climate changeEnvironmental healthHealth information technologyHealth surveysPrevention, policy, and public healthPreventive medicine ePublished: 15 December 2020 Issue Published: March 2021 Copyright & PermissionsCopyright © 2020 by American College of Physicians. 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