Sustainable Healthcare In Medical Education: The Student Perspective


 Background:It is now a General Medical Council requirement to incorporate sustainable healthcare teaching (SHT) into medical curricula. To date, research has focussed on the perspective of educators and which sustainable healthcare topics to include in teaching. However, to our knowledge, no previous study has investigated the perspective of both undergraduate and postgraduate medical students in the UK regarding current and future incorporation of SHT in medical education.Methods:A questionnaire was circulated to clinical year medical students and students intercalating after completing at least one clinical year in a London University. The anonymous questionnaire consisted of sections on the environmental impact, current teaching and future teaching of SHT.Results:163 students completed the questionnaire. 93% of participants believed that climate change is a concern in current society, and only 1.8% thought they have been formally taught what sustainable healthcare is. No participants strongly agreed, and only 5 participants (3.1%) agreed, that they would feel confident in answering exam questions on this topic, with 89% agreeing that more SHT is needed. 60% believe that future teaching should be incorporated in both preclinical and clinical years, with 31% of participants preferring online modules as the method of teaching.Conclusion: Our novel study has stressed the lack of current sustainable healthcare teaching in the medical curriculum. From a student perspective, using online modules throughout medical school presents an attractive method of incorporating sustainable healthcare teaching in the future.

impacting health outcomes.
The healthcare sector also has a signi cant impact on the environment, with the National Health Service (NHS) having the largest carbon footprint in the UK public sector [7]Therefore, the healthcare sector has a responsibility to improve its sustainability. Sustainable healthcare (SH) can be de ned as "education about the impact of climate change and ecosystem alterations on health, and the impact of the healthcare system on the aforementioned" [8]. Between 2007-2017, carbon emissions from the health and social care sector reduced by 18.5%, despite increased demand for services, as stated by the NHS Sustainable Development Unit (SDU). The SDU have suggested that while this improvement is promising, we are unlikely to reach the 34% reduction target by 2020 [7].
In addition, the ongoing COVID-19 pandemic has placed future environmental concern at the forefront of debate. A poll involving 15,951 adults from 16 countries investigated the importance of the environment in the governmental responses to COVID-19. Approximately 3/4 of those surveyed in the UK believed that the government should prioritise environmental protection post-pandemic [9] Rume and Islam's literature review summarised the positive and negative effects on the environment that COVID-19 has had thus far. Positives are associated with lockdowns held in many countries worldwide and reduced economic activity, whereas negatives are associated with reduced recycling and increased demand for personal protective equipment (PPE) [10]. PPE is particularly pertinent for SH, the World Health Organisation (WHO) has estimated that 89 million medical masks have been needed each month during the COVID-19 pandemic. Furthermore, in March 2020, the WHO projected that PPE production would need to be increased by 40% to meet international demand [11] Belesova and colleagues suggested that the COVID-19 pandemic could be used to introduce environmental and economic policies that can bene t long-term health outcomes [12] Moreover, in May 2020, more than 350 organisations across 90 countries, representing over 40 million health professionals, wrote to G20 leaders endorsing a similar post-pandemic response to that of Belesova and colleagues [13].
Therefore, while undoubtedly a human tragedy, the COVID-19 pandemic has reiterated the importance of sustainable economic recovery and healthcare for our generation and generations to come.
Alongside current healthcare professionals, healthcare professionals in training are arguably best placed to be educated about SH relevant for current and future generations, thereby enabling them to actively contribute towards the UK target of reducing carbon emissions by at least 100% between 1990 and 2050 [14,15]. Re ecting this, the General Medical Council (GMC) have stated in Subsection 25 of their Outcomes for Graduates document that newly quali ed doctors should understand and be able to utilise principles of SH in their medical practice, and that universities had until 2020 to put in the necessary teaching to support this [16,17]. However, the 2020-2021 Planetary Health Report Card (PHRC) suggests that SHT may still be lacking on an international scale. The PHRC evaluated 62 medical schools worldwide in ve broad categories, including the curriculum itself. Only two medical schools evaluated scored over 80% as their overall score. In comparison, at least 24 medical schools scored lower than 50% [18]. Therefore, it appears clear that SH in medical education is still in its infancy, with relatively little published thus far [19,20] Tun's research gained the perspective of educators regarding the integration of SH teaching (SHT) in medical education [21]. She identi ed several obstacles to introducing SH in medical curricula according to educators, including the perceived lack of teaching time. Furthermore, several enablers were identi ed, with student interest being a particularly notable one. However, Tun's research did not consider the perspective of current medical students. She also identi ed a concern that medical educators may not be su ciently informed to teach students well [21]. To address this, the use of peer teaching from fellow medical students has been proposed by Green and Legard. While they summarised the views of several medical schools, this included a relatively small cohort of 29 medical students [22]. Furthermore, Gandhi et al's paper suggested an approach for incorporating SHT in postgraduate medical education, based on Mortimer's 2010 paper. It discusses how applying ve core principles can lead to an outcome of reducing carbon emissions without compromising healthcare services. This includes preventative medicine, encouraging patients to self-manage conditions more, lean pathways, low carbon alternatives and operational resource use [23,24]. Additionally, Teherani et al. surveyed 52 SH experts, who identi ed that most teaching should be undertaken in preclinical years [19] There does not seem to be a clear consensus regarding how to best integrate SH into medical curricula. Part of this lack of clarity may be explained by the fact that, to our knowledge, no previous study has investigated the perspective of both current undergraduate and postgraduate medical students in the UK regarding current and future incorporation of SH in medical education.
Therefore, gaining insight of the students' perspective on SH will enable us to identify pitfalls in current medical education, and approaches to maximise the e cacy of teaching in the future. Therefore, we aim to identify: Whether current medical students have been taught what SH is.
Whether current SHT is su ciently incorporated into the medical curriculum.
The importance of SH from the perspective of current medical students.
Preferred approaches to include SHT in the medical curriculum.
We hypothesised that SHT is not su ciently incorporated into the medical curriculum. We also hypothesise that while current medical students think that SH is important in daily clinical practice, they have not been adequately taught what it is in a formal setting.

Participants
Inclusion criteria for choosing participants for this study involved current medical students in clinical years at a London University (years 3, 4 or 5 respectively) or students currently intercalating having completed at least one clinical year. Prospective students were invited via central emails and social media to complete the questionnaire, which was open over a 2 week period.

Materials and Design
The anonymous questionnaire consisted of four sections: demographics, environmental impact, current teaching and future teaching. Demographic data collected included gender, year of study and whether they were studying for an undergraduate or postgraduate medical degree. Questions asked regarding environmental impact, current teaching, and future teaching are summarised in Tables 1 and 2, and Figs. 2 and 3. Environmental impact and current teaching sections of the questionnaire were assessed via a Likert scale. Microsoft Forms was used to design the questionnaire and interpret the data collected. Microsoft Excel was also used to interpret the data. All questions had to be completed in order for the participant to be able to submit the questionnaire.

Environmental impact
Answers to statements on environmental impact in relation to both current society as well as medical practice are summarised in Table 1.

Current teaching
Answers to statements on current SHT in the medical curriculum are summarised in

Demographics
A total of 163 responses were received from a potential total of 851 respondents, which is a response rate of approximately 19%. Yale University conducted a similar study amongst healthcare students, receiving a response rate of 28%. Their paper describes the possibility of selection bias, as students who are already interested in SH were more likely to respond to the questionnaire compared to others [25]. This limitation could potentially apply to our study too. At Yale, it was shown that more women regarded SH as an important issue compared to men [25]. Our study showed that 70% of respondents were female. Females having stronger views towards SH could have caused this high response rate which again may have potentially caused selection bias. Out of our respondents, 76% were undergraduate students and 24% were postgraduate medical students, which re ects the proportion of students on the undergraduate and postgraduate courses respectively.  [27]. Therefore, it is unsurprising that 83% of participants agreed or strongly agreed that climate change was a signi cant concern in current society.

Environmental impact
Furthermore, 86% of participants believed that daily medical practice should be environmentally friendly, and 72% felt that daily medical practice currently adversely impacts the environment. This reiterates the NHS Long Term Plan, which aims to halve its carbon footprint by 2025, improve its impact on air quality, and reduce single use plastic in the NHS [28]. Moreover, our ndings again re ect the Yale University study, which found that 90% of respondents felt that healthcare professionals should consider their impact on the environment in daily clinical practice [25] 4.3 Current teaching One of the GMC outcomes for graduates is "newly quali ed doctors must be able to apply the principles, methods and knowledge of population health and the improvement of health and SH to medical practice" [16]. Despite this clear statement, our results showed that 79% of students did not believe that their course had made this clear.
Our results highlight the lack of awareness of SH in medical education. 91% of students felt that they had not been formally taught what SH is. Similarly, 92% of students did not believe that they had been formally taught about environmentally friendly plans established in the NHS. This echoes El Omrani et al's study, which identi ed that only 15% of 2817 medical schools internationally included teaching about climate change and its impact in a health context [29] However, there is a demand to incorporate SH into their curricula, with 89% stating that this is required. This reinforces Tun's ndings, which state that medical educators describe the "demand from students" as an enabler to introduce further SHT [21]. A letter to the editor by a third year medical student reiterates the "social silence" surrounding the topic of climate change, and portrays the urge to raise awareness around this pertinent issue [20]. Our ndings solely focus on the student perspective, and reinforce the lack of knowledge around SH despite student interest.
Tun mentions di culty in assessing learning as a barrier to introducing SH into the curriculum [21]. We found that 92% of students would not feel con dent about answering exam questions regarding SH. Therefore, our results highlight that perhaps the more important issue at hand is the lack of education amongst students rather than how student knowledge on SH can be assessed. Using formative but mandatory assessments has been suggested by Schwerdtle et al. [30]. This may help to transition students while incorporating SH topics in summative examination. Many medical schools have student selected components embedded in their curricula. These may also provide an opportunity to introduce such teaching to medical students. This could be linked to quality improvement, which forms its own section in the GMC Outcomes for Graduates [16]. Furthermore, if associated with a clinical supervisor, this may help to give a clinical insight in SH, alongside providing an opportunity for current healthcare professionals to learn about SH as well. Alternative methods of incorporating teaching that have been mentioned in literature include re ective writing, short answer questions in summative examination, and part of clinical placements [31]. The former could also be linked to Sect. 2 of the GMC Outcomes for Graduates: "Professional and ethical responsibilities", speci cally section 2t, which describes the importance of a professional development portfolio [16] Methods of embedding SH into the curriculum has been discussed by many. Tun found that medical educators described the curriculum as being overcrowded [21]. One of the educators in Tun's research mentioned how teaching students all relevant topics would in fact never allow them to graduate within 5 years of medical school. In contrast to this, Mortimer and Walpole found that educators were fascinated by the reach that implementing SH into the curriculum had for entire cohorts of students [32]. A solution to incorporating SH into the medical curricula may be to integrate it into topics already in the curriculum [21], instead of debating what to remove from the syllabus. By doing so, this will further embed the relationship between SH and current medical practice.
We found that the student perspective was divided on this, with 49% stating that there was space in the curriculum for SHT to be incorporated, and 31% neither agreed nor disagreed. While some educators believe the curriculum lacks space, the student perspective suggests that embedding SH may be feasible.
Given the interest students have displayed to learn more about this topic, it may be that how SHT is implemented in future teaching will determine whether there is su cient space in the medical curriculum, particularly for this 31%. This may not only be relevant for UK medical schools, but possibly on an international basis. Incorporating SH into teaching has been a topic of discussion in the US and Australia [25,33,34], suggesting that a lack of SHT in current medical education is not simply a UK-centric issue, but may in fact be an international issue in medical curricula, which therefore needs to be urgently addressed.

Future teaching
The student perspective suggests that online modules (31%) are the most popular method of incorporating SH into medical education. However, this was similar to lectures (26%) and small group teaching (24%), suggesting that students are not as certain about how they would prefer to be taught.
The COVID-19 pandemic may have skewed this result however, as online modules were the only option which did not involve in-person interaction [35]. This uncertainty on how best to be taught SH is also re ected by educators, with an Australian university study nding that two-thirds of educators would not know the best way for their students to be taught [33].
Students were also asked to rank who would be best to teach SH. Healthcare professionals were the preferred option, followed by university non-clinical staff (44% and 28% as most appropriate choice respectively). Tun's research identi ed that medical educators may not be able to effectively teach students due to a lack of knowledge [21]. This appears problematic given our ndings suggest that students would prefer SHT from healthcare professionals and university non-clinical staff. Additionally, Green and Legard's letter to the editor suggested that peer teaching would be bene cial. However, this contrasts with our ndings, with only 9.2% preferring peer teaching as the best way to teach SH. While their ndings included students from several medical schools, their suggestion was based on a relatively small sample size [22]. In comparison, while our study only included one medical school, the sample size was much greater (n = 163). Despite the Royal College of Physicians including sustainability as part of its de nition of quality of best possible patient care[36], the lack of knowledgeable healthcare professionals in SH [21] provides an obstacle for effective teaching.
The use of shared online resources may provide an appealing method to overcome these obstacles, as re ected by our ndings. It has been previously described that pooled resources across medical schools can help to minimise the lack of SHT material available [20][21][22]. Online teaching in medical education has been an increasingly prevalent topic in literature over recent months due to COVID-19. There are several key bene ts of online teaching highlighted in literature, including increased access to teaching resources from world leaders in their respective elds [37]. Online teaching has provided more exibility in learning, with a systematic review arguing that the shift to online resources may boost students' incentive to learn [38], and a study found 97.2% of students agreed with online teaching as an alternative teaching method during the pandemic [39] .
But is online teaching only relevant as an alternative to in-person teaching? A recent systematic review and meta-analysis found that a combination of in-person teaching and online resources may be effective in medical education [40], with a 2014 systematic review stating that that online teaching may be better than in-person teaching in respect to "knowledge and skills gained" [41]. Furthermore, Dost et al. conducted the rst study to investigate the impact of this pandemic on online teaching across UK medical schools, with 39 of 40 medical schools responding. They found that there was a signi cant increase in time spent using online resources compared to before the pandemic, concluding that a combination of online resources and face-to-face teaching should be incorporated in the future [42]. It therefore makes sense for medical schools to continue utilising online resources for certain aspects of teaching post-pandemic, as highlighted by Cheng and Liu [43]. Our results suggest that SHT in medical education may be one of these areas to continue delivering online post-pandemic, which will help to disseminate material amongst medical schools. This may prove a particularly pertinent method of teaching, given that medical schools both nationally and internationally are concerned about SHT [44]

Strengths and Limitations
To our knowledge, no previous study has investigated the perspective of both current undergraduate and postgraduate medical students in the UK regarding current SHT in medical education. This is the rst study that has investigated the preferred method of incorporating future SHT in medical education from a student perspective. Therefore, this study provides signi cant insight that should be taken into consideration when incorporating SHT. Although previous studies have asked students for opinions, the sample size for our study was much larger (n = 163).
Despite having a large sample size, we only collected data from one London medical school. Running this study amongst multiple medical schools across the UK will help us gain further insight into the student perspective in the future. Our questionnaire did not have many 'open questions', meaning that students could not entirely voice their opinion. Furthermore, we only distributed the questionnaire amongst students in their clinical years, which meant we did not gain the insight of students in preclinical years. We decided not to distribute the questionnaire to preclinical students due to their relative lack of exposure to a clinical environment. Use of a Likert scale for most of our questions meant that we did not obtain much qualitative data. Signi cance of our ndings could also not be determined as we did not perform any statistical analysis. 4.6 Future Research SH in medical education remains a relatively novel concept, with limited research thus far. Our study gained the perspective of medical students in clinical years from a London university. Distributing a questionnaire among medical schools across the UK in the future will allow us to gain further insight on the student perspective of SHT. Additionally, repeating this study in the future will allow us to longitudinally compare whether SHT has improved in medical education after medical schools have had more time to incorporate and develop such teaching in their curricula. Using small focus groups may allow students to further articulate their views on how to embed SH into the curriculum in a more qualitative manner, and enhance SHT.
While we only focussed on the perspective of medical students in clinical years, it may prove useful to gain insight from preclinical students, who may have a less medical perspective on SH, and provide a more generalised approach instead. Finally, to gain an updated insight into the medical educator perspective, distributing a similar questionnaire, but tailored to educators, across all UK medical schools will allow us to compare and contrast this to the student opinion, and identify an optimal method to implement SHT.

Conclusion
This is the rst study to investigate the perspective of both undergraduate and postgraduate medical students in the UK regarding current and future incorporation of SH in medical education. Students believe that it is important for daily medical practice to be environmentally friendly, but currently isn't.
Most students do not feel that they have been formally taught what SH is, and would not feel con dent on being examined on this topic, despite it being a GMC requirement. In the future, students identi ed that the optimal method of SHT would be online modules from healthcare professionals in both preclinical and clinical years. SHT in medical education is currently limited. Therefore, further research is required to identify the best way to inform the next generation of doctors about the importance of SH, and how to incorporate it in their daily medical practice. 6.2 Consent for publication All authors consent for publication of this research article.

Availability of data and material
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
None.

Funding
None.

Authors' contributions
Dhruv Gupta and Lahvanya Shantharam wrote the main manuscript text for this research article. Dr Bridget Kathryn MacDonald gave senior advice and reviewed the article.

Acknowledgements
We would like to thank St George's, University of London for their cooperation and help in circulating the questionnaire within the university for our research.  Student perspective ranking who would be best to teach sustainable healthcare. 1 = most appropriate, 4 = least appropriate. Figure 3