Advocating for Dedicated Sustainability Experts in Healthcare System Leadership: A Roadmap  

Part 1: Build a Team

Building a team is a crucial first step to implementation sustainable change. It may take several years of discussions before change is made, and thus incorporating students in your class and below ensures your ideas will live on past your graduation from an your institution. 

1. Find like minded students by checking to see if there is an existing planetary or climate health organization or point people at your med school (e.g. reach out to upperclassmen, residents, deans).
2. If there is no established organization, consider starting a new chapter of MS4SF at your school if a similar organization does not already exist. Please note, an existing organization can also become a MS4SF affiliate.
3. Create an initial list of potential mentors and be sure to have a centralized list with all interested contact information for future access.
   1. Students: Reach out to upperclassmen or students in existing sustainability organizations (if they exist) about research mentors or organizational champions that they have worked with in the past.
   2. Faculty: Reach out to medical school, health systems, and administration to see – cold emailing, LinkedIn, ask for introductions from other medical students.
   3. Administrative/Staff: The support staff of healthcare institutions can be very helpful in contact and maintaining support from faculty and medical school leadership team.

Part 2: Decide on a Target Audience

Consider which institutions you’re targeting whether it will be an undergraduate campus, medical school, affiliated health system, or independent healthcare clinic. First, check if a sustainability expert (or similar) position already exists for this institution. If not, consider if there is a specific department or similar position in the organization chart that could take on the responsibilities for a sustainability director.

1. Once you have decided on an target auidence, consider how this position would be paid for, and who would decide where that budget is coming from, as one of the main arguments for appointing a sustainability director (see below) is that it saves money.
2. Whether a sustainability expert is appropriate for that institution or the scope of their work may vary significantly based on which institution type you’re aiming to make changes at (not all institutions listed may be applicable depending on the med school, there may also be other institution types not listed that could be relevant).
   1. Undergrad campus – as a med student you might have limited influence on their decision making, most universities seem to be moving in the step of having some kind of climate sustainability plan.
   2. Medical school – potentially more influence as a medical student, although sometimes the sustainability-related operations of a medical school (e.g. energy usage, facilities) are overseen by a department shared with the broader university or health system.
   3. Hospital system – operations of affiliated health systems are likely not under the jurisdiction of the medical school, you would have to find leverage from within the system (e.g. a motivated attending or department chair) to work with.
      1. Independent clinic – will likely have their own administrative staff, depending on funding resources may or may not have an existing position
   4. Consider whether there is some larger group (e.g. national or international) or initiatives of some kind that already targets the institution type you’re targeting. It’s possible that the institution you’re targeting is already affiliated. Examples:
      1. Practice Greenhealth – focuses on sustainability in hospitals and health systems
   5. Consider if there are legislative or regulatory factors you could leverage.

Part 3: Create Communication Strategy 

Drafting a powerful but succinct email to a high-level administrator declaring involvement in the PHRC, requesting a meeting, or outlining demands can be an intimidating undertaking. We hope that the following template gives you a useful starting point. Of course, feel free to adapt it to serve your school-specific contexts. 

Dear Deans ____,

___ and I are medical students leading the (insert school group). We are a group of medical students united around the issue of climate and health. We are passionate about understanding the relationship between climate and wellbeing, and how we as future physicians and leaders can ensure we are prepared to treat patients in this rapidly changing world. Climate change will lead to adverse health effects in our patients, including but not limited to heat-related morbidity and mortality, respiratory diseases and allergies, water- and vector-borne diseases, and food insecurity. The effects of climate change are already disproportionately affecting minorities and indigenous peoples, further reinforcing existing structural health inequities. (insert medical school) is poised to make sustainable change at the institutional level.

To that end, we are planning to complete the Planetary Health Report Card. With the Planetary Health Report Card, we seek to evaluate (insert medical school)’s commitment to planetary health. The different metrics include 

1) planetary health curriculum, 2) interdisciplinary research in health and the environment, 3) university support for student planetary health initiatives, 4) community outreach centered on environmental health impact, and 5) sustainability. We are joining an effort of medical institutions across the world. The Planetary Health Report Card was initiated at UCSF last year by a group of students and its metrics were developed in close conversation with stakeholders and experts across the medical community.

We hope this report card will serve as a needs assessment to educate us on both our community’s strengths and its areas for growth in the field of planetary health. We would love to meet with you to share our findings as well as more about our group’s initiatives on planetary health at (school).  If this is possible, we can be flexible around your schedule and would be grateful to meet whenever would work best for you. 

Gratefully,

___________

Part 4: Prepare your “Asks”

The PHRC can help frame conversations around institutional planetary health engagement but the ideas you propose to your administration will depend on your school-specific needs, capacity of your group, and the availability of funding. Below are some ideas for proposals (and examples of schools that have implemented them). 

1. Longitudinal integration of planetary health topics in your curriculum (for example, see this recent paper by Emory medical students outlining a curriculum proposal)
2. A funded research center specifically for planetary health projects (for example, like the C-CHANGE Center at Harvard)
3. A funded student environmental fellowship for medical students to engage with community (for example, this environmental scholars program) 
4. A free, community-facing educational course about planetary health topics (for example, UCSF launched a “Mini Medical School for the Public” series on the health emergency of climate change)
5. Institutional divestment from fossil fuels 
6. Grants for sustainability QI projects 

Consider gathering engaged students +/- faculty in a meeting to brainstorm “asks” and ensure all stakeholder voices are heard. 

Part 5: Meet with Target Audience 

So, your deans agreed to meet with you and are willing to entertain the ideas of your campus environmental group. Below are some tips for ensuring a productive meeting, sprinkled with some advice from those that have had successful (and not so successful) meetings. 

1. Set the meeting far in advance. Deans are busy people. Allow for at least one month of buffer between reaching out and your intended meeting date. We recommend choosing a date that lands after you will have completed the PHRC but before you have turned it into the leadership team. However, depending on your school-specific context, you may want the meeting to take place at a different time in the process (or depending on the willingness of your administration, at multiple times throughout the process!). 
2. Create an agenda. Once you have established a meeting date, time, and length, draft an agenda that maximizes productivity of the meeting. What are your goals? What specific “asks” will you propose? Who in your team will be in charge of discussing each item? For an example agenda, see the *meet* section. 
3. Create a one-pager. While we recommend that you print out the entire PHRC so that your administration can peruse it at a later time, we also suggest creating a clear one-page cover sheet with a summary of your findings and your specific asks.
4. Ask for input. Are there other advocacy groups that have recently met with the administration? Would your student council (or similar body) be willing to give you feedback on your proposed agenda or advocate for your interests through their channels?   
5. Attend/host a mock practice session. While not necessary, a mock session can be an opportunity for you to practice your prepared presentation, as well as to practice navigating unanticipated questions or situations. Consider asking a faculty mentor to practice with you or attend our institutional advocacy session in March.
6. Think about how you would navigate challenging questions/scenarios. Even if you have prepared your presentation to a tee, your administrators’ responses may derail your plan. In order to prevent those questions from undermining your goals, think about how you might respond to the following scenarios:
   1. Your dean says that “climate change is too political to be covered in the curriculum”.
   2. Your meeting is only 45 minutes long and your dean has already spent 20 minutes dissecting what your team wrote for one single metric, which is not an important metric for your overall goals.
   3. Your dean expresses that they don’t want the medical school grade publicly displayed online.
   4. Your dean expresses that the larger institution is responsible for sustainability, not the medical school specifically
   5. Your dean says that due to the Covid-19 pandemic, the medical school does not have any spare funding to financially support any of your proposals. 
   6. Your dean questions why they should put stock in this set of metrics developed by medical students at a different institution/in a different country. 
7. Meet! Make sure to try and establish a positive, collaborative tone, framing the PHRC not as an antagonistic external grade, but a tool for identifying strengths and possible areas of improvement that you will work with the school leadership to address. 

Example agenda: Overall Goals: Set goals for the meeting. You may not want to share all of these with the administrators, but you want your student team to be on the same page. Examples include: 1. If meeting before release - Establish support for completing the report card (specifically: support for answering our questions, agreement to meet again, support for publishing the results) 2. Establish support and plan for including the needs identified in the report card in the school’s strategic plan. 3. Determine best stakeholders to meet with in order to accomplish goals 4. Plan to meet again  Tip - highlight bullet points where each goal is incorporated into the agenda. This helps ensure you have a plan for accomplishing your goals Agenda:  Assign speakers for each section/bullet point, assign a notetaker 1. Intro  Name, year: Try to include a diversity of students from M1-M4 year. Fill the Zoom screen — include as many students as possible to show there is broad student support for your efforts! Briefly summarize your meeting agenda: Meeting to explain PHRC, answer questions, present overall goals you’d like to work toward Briefly describe how climate action fits within the school mission Consider sharing a short, personal climate-health story 2. Overview of the Planetary Health Report Card Structure and goals of the PHRC a. If available, include data on student desire for planetary health or climate change education at your school b. It is also worth mentioning the expanding scale of the PHRC as an indication of this topic’s importance Nationally/Internationally c. Show the 2020 report card (SCREEN SHARE — they want to know their competition) Provide Link to full report card metrics or your complete report card 3. Questions  What questions do you have for us?  4. Findings a. Even if you meet with your admin before you are completely finished filling out the report card, make sure to have 2-3 key findings on hand.   b. Depending on your school’s support, you may have only one meeting to present your findings — be realistic about what you can accomplish in the limited time — highlight the findings you think are most important to address 5. Presenting short-term & long-term goals  Opportunities can be broad and offer a vision, but make sure to present a few tangible goals as well. a. Be ambitious but also try and have a variety from ‘low hanging fruit’ that are easy wins and don’t require funding (for example, the addition of some slides on climate change into a few lectures), to larger long-term dreams that require funding/big collaboration (for example, establishing a center) b. Offer a timeline — this helps to clarify expectations on both sides.   c. Consider the following examples:  Opportunity to lead X medical schools (your region, your city, etc) in climate and health education Opportunity to collaborate with your hospital and reach net-zero emissions Opportunity to improve metrics before report card is submitted in March Goal to address one specific PHRC finding — be specific Goal to improve PHRC score one letter grade by next year Goal to develop a climate action plan for the medical school Goal to incorporate PHRC findings into the medical school’s strategic plan Goal to have your medical school dean, head of hospital, and university president meet to establish institutional climate action goals 6. Plan going forward If needed, ask admin to send recommendations for faculty/staff who can help with X project, who you can contact to review the report card, etc If meeting before the PHRC release, let admin know that the report card will be submitted in March and released around Earth Day Plan to meet again to discuss additional findings or to work on accomplishing goals Feedback & Questions  What questions do you have for us? Thank you, __________

8. Send an immediate follow-up email. Thank the administrator for their time, follow up with links to any referenced resources, and reiterate any action items that you established in your meeting. Promise to keep them informed when the PHRC results are published. 
9. Follow-up with PHRC results. In addition to showcasing the final product and highlighting where your school stands relative to others, this is an opportunity to point out what other medical schools have excelled at. For example, have faculty at another school received a grant to integrate climate change curriculum longitudinally? Does another institution have community partnerships with local environmental justice organizations? Propose implementing those initiatives at your medical school, using the other schools as a model. 
10. Be persistent. These changes are not going to happen overnight. Keep up the momentum and continue to meet with stakeholders.

Part 6: Explore Additional Resources

• Practice GreenHealth Case Study on assembling a green team with ROI analysis 
• The impact of executive leadership dedicated to Sustainable change 
• HHS Health Sector Climate Pledge
• Inflation Reduction Act, Federal support for admission reduction and climate resilience work
• Link to Healthcare Sector climate pledge and signatories
• MS4SF Curriculum Chairs developed this MS4SF Curriculum Guide that contains curriculum reform proposals, sample syllabi, and lesson materials

Example Case Study: Brown University 

Brown University’s medical school consists of about 160 medical students per year with 1,400 faculty listed on staff. It is the only medical school in Rhode Island. Relatively connected institution where everyone working on climate generally has at least heard of everyone else. Important factors considered in order of importance below

• Part 1: Build a team
  • Brown overall has a dedicated sustainability office. From what I can tell, they are mostly responsible for managing building operations and implementing projects where Brown has direct control (undergrad campus, and med school). This mostly negates the need to lobby for the hiring of a sustainability expert at Brown, as they seem well funded and staffed. Therefore, if I were to implement this program at Brown I would target the affiliated health systems.
• Part 2: Decide on a Target Audience
  • Brown overall has a dedicated sustainability office. From what I can tell, they are mostly responsible for managing building operations and implementing projects where Brown has direct control (undergrad campus, and med school). This mostly negates the need to lobby for the hiring of a sustainability expert at Brown, as they seem well funded and staffed. Therefore, if I were to implement this program at Brown I would target the affiliated health systems.
  • Brown is affiliated with two main health systems with multiple hospitals at each. There are a few emergency medicine attendings who work at some of these hospitals, help coordinate “green teams” at their ED’s, and are involved in statewide organizations (see RIMS). As far as I’m aware they don’t hold any official positions and seek independent funding / pursue research and QI projects in sustainability on their own time. As such they are limited on time. They are well connected with some stakeholders, although it is difficult for a med student to determine the degree of connection as well as the relationship between different hospitals. Mentors like this are helpful for connecting students with administrators at health systems, but would likely not be able to directly control hiring a sustainability expert. They would also likely be supportive in looking over any proposal or presentations and putting their support behind such proposals.
  • There are a few research professors (some clinical MD’s some nonclinical PhD’s) who do research in the intersection of climate and health. At Brown, I’ve found most of them to be doing work in epidemiology. These professors may have connections with either the medical school, undergrad campus, or health systems. However, being mostly focused on research it would be unlikely that they would be involved with hiring a sustainability expert. They could be helpful in identifying relevant research for background in putting together a proposal.
  • Rhode Island Medical Society (RIMS) – a statewide organization for doctors that has a sub-committee focused on climate change education. This would likely be a good forum to get connected with medical professionals across the state, although the organization itself likely does not have any direct influence over any medical schools, universities, or health systems.
  • Rhode Island Free Clinic / Clinica Esperanza – free clinics that medical students volunteer at, I have not personally tried implementing any type of project here, but there are upperclassmen medical students who have worked longitudinally with these free clinics for a while and I would start by reaching out to them to get connected with the free clinic administration. Note that resources here may be constrained depending on the clinic’s budget or headcount.
• Part 3: Email Templates 
  • Direct copy from the above template.
• Part 4: Preparing your “Asks”
  • At Brown, we wanted to ask for longitudinal integration of planetary health topics in our curriculum. Thus, we went ahead and presented the supporting research for curriculum integration on climate smart healthcare.
• Part 5: Meet with Target Audience
  • Follow up with the target audience about getting involved in the next steps and staying connected on the shared media!