Trevor Thompson, Professor of primary care education and head of teaching for primary care, Bristol Medical School, University of Bristol

Philippa Clery, Core psychiatry trainee (North Central London); NIHR academic clinical fellow (University College London)

Published in JHH 18.3-Shifting the paradigm

Background to the debate

In Bristol Medical School holism has been formally embedded in the curriculum since 2001, through our whole person care helical theme. For instance we have portrayed the human predicament as a scaled holarchy from the cellular to the global. By taking a systems perspective, students get to see how the same principles unfold in nominally distinct domains. We show, for instance, a slide of the once gaping hole in the polar ozone layer and ask them to suggest an equivalent in the human body. One possible answer is vitiligo – an auto-immune condition which strips the skin of its UV protective layers of melatonin. The aim is to help students realise how human health is evidentially linked to a larger whole. And that whole is in trouble as the climate emergency unfolds.

Because of this, the importance of referencing the global dimension has become pressing and it is fair to say that medical schools have struggled to keep up. With the University of Bristol declaring a climate emergency in 2019, we have just approved a new helical theme called Planetary health and sustainability. Other examples include ethics and self-care. Helical theme leads have the authority to call out curriculum planners if they do not include material on a given theme – so this gives us some leverage.

We are currently planning a range of new interventions, with lectures on planetary physiology and planetary pathology, which mirror the over-arching themes of the first two years of the course. In the clinical years students will be charged with quality improvement projects aimed at creating the elusive net zero NHS (Schroeder et al, 2012).

Though we do have many true activitists, a perennial challenge is getting most students to feel issues of the global environment are relevant to a training in clinical medicine. Students often feel a total lack of agency. In other words, they feel that they have no way of changing the system and thus find it hard to engage. This is how we landed on the idea of elective travel. We sought an educational inter vention that would quicken the pulse by causing medical students to examine their own behaviour in relation to the global environment. By tradition, in the UK, senior medical students make multiple long-haul flights ‘on elective’. For instance, in 2018, 177 Bristol students visited 38 countries, at an average personal carbon cost of 3,800kg eCO2 – similar to the annual per capita emissions of countries such as Mexico, Romania and Lebanon. Figure 1 shows the routing of a typical elective. With these stark statistics we decided to put the long-haul elective on trial.

How we structured the debate

We staged a debate around the deliberately provocative title ‘This house believes, in this era of climate emergency, it is a moral wrong for medical students to fly long-haul on elective’. We chose speakers to throw the issues into maximum relief. A junior doctor shared her awesome elective odyssey – from rural health clinics in the Philippines to a gleaming tertiary hospital in New Zealand, via the hills and beaches of Bali. This involved 11 individual flights as illustrated in Figure 1. An engineering student quantified Bristol’s elective carbon footprint and surprised us with the thermal impact of ‘contrails’. A seasoned international development medic iterated the benefits of elective travel, for our sense of the world and of ourselves, arguing ‘we can’t put aeroplanes back in the box’. A fourth speaker provided the traditional dismal litany of climate change’s impact on human health – both now and projecting forward to when these students will be midcareer. Students were able to cross examine the witnesses, and an ethicist rounded things up, with reflections on wants versus needs and questioning the idea of ‘moral sainthood’.

Debate works – no debate!

The motion was defeated with 31% in favour and 69% against. Because the arguments were dished up with strict equipoise, with ethical guidance and with no obvious hope of a ‘right’ answer, students were required to reason around the issues and figure out their own positions. They got riled up as well as clued up, in ways unimaginable within the standard lecture format. For instance, one student lamented ‘you had these experiences – why should we be denied them?’. In future iterations we would do more to democratise the student voice. In the lecture setting, the brave and the articulate can dominate. With our lectures currently online, we can use breakout rooms to allow students to rehearse arguments in small groups and chat before eliciting and selecting questions. We believe this format is reproducible – it should be possible to track down speakers in these categories within any major institution.

Final thoughts

For us as authors, our electives were seminal, lifechanging, experiences. Currently, due to Covid, most students are actually on elective in UK hospitals and practices and probably not having the same intensity of peak experience. If we are to reconfigure the whole of society to be carbon neutral there will be both sacrifice and scope for amazing creativity. One student had her plans to cycle to a Greek migrant centre scuppered by Covid. That the long-haul elective was not found morally wanting did not diminish, and possibly enhanced, the educational value of the intervention. The key learning from this intervention is that what seems to work best is to discuss the environmental crisis in ways that relate directly to students’ lived experience.

We would like to acknowledge the enthusiastic contribution of our co-presenters Frank De Vocht, Jonathan Ives, Matt Ellis and Kieran Tait.

Reference

Schroeder K, Thompson T, Firth K & Pencheon D (2012) Sustainable healthcare. Wiley-Blackwell.