PONE-D-23-31947Fostering medical students’ critical consciousness on climate change, health, and equityPLOS ONE

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PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

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Reviewer #1: Partly

Reviewer #2: Yes

Reviewer #3: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: N/A

Reviewer #3: No

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Overall, this paper has utility for educators at other institutions interested in creating more climate content for their students. It is unclear how much of this one example is applicable generally, since a unique feature of the effort at this institution is that the existing course directors played a key part in introducing new content.

More importantly, the information about the course may be too scant to be useful. And not enough detail warrants much more detail, which isn’t feasible in this sort of paper. I would thus streamline the paper to the crucial, transferable content, eliminating details that are not relevant to the overall architecture of the course, which will also make this paper more readable. I hope that my specific comments can provide some additional guidance.

Of note, the writing could use the librarian’s once-over. “At present” not “presently”. “Effect” not “affect”; “synthesize: not “synthesize ..together” etc. And that’s just the opening section

p. 1 “surrounding environment” This is vague and can be anything. Please be clear about what aspects of the surrounding environment you mean, as this orients your argument.

p. 2

Building teaching capacity… financial support” Consider including:

Blanchard OA, Greenwald LM, Sheffield PE. The Climate Change Conversation: Understanding Nationwide Medical Education Efforts. Yale J Biol Med. 2023 ;96(2):171-184.

“Though leaders have recommended learning objectives…” Consider including: ]

Sorensen C. Campbell H, Depoux A. et al. Core Competencies to Prepare Health Professionals to Respond to the Climate Crisis. Plos Climate 2023; 2(6): e0000230.

“Considering the education need and expert recommendation” It’s very important to be precise here, as this represents the transition from the previous general overview/state of climate education to this institution’s response. What exactly was the CoP convened to address? Start this paragraph with “In order to address…” Then state what the goal of the CoP was (e.g. In order to address the need for a more robust climate curriculum with measurable goals, we…”

How were the learning objectives and goals derived (based on what sources?)

Materials and institutional expertise: vague

Assessment tools: Unclear how these were developed, given that no intervention has been developed, according to this description

Where does the Health and Equity come from? This hasn’t been part of the intro. Is this what was meant as part of the ‘education need and expert recommendation?” Also, it is hard to understand how the group, given the authors’ recognition of all the constraints preventing climate education, managed to get this thread into the curriculum. What seems to be needed here is more focus. Instead of starting the paper with all the problems, why not say something like (in a nutshell): “Although many institutions have confronted difficulties in incorporating climate change awareness into their busy curriculum, our medical school’s first-year climate, health, and equity course successfully addressed this barrier by integrating multiple urgent concerns students are confronting today. These include environmental threats, health equity, and [whatever other urgency the thread contains].”

p. 3 evolves from? You must mean ‘evolves beyond’ or something like that

“We intended…humanities” The reader recognizes this as a big ask and hopes that what follows will illuminate how these goals were addressed

p. 4. The power of the course directors is key here; the lack thereof would be a major obstacle at other institutions

“118 students engaged in thread content”: isn’t there a better way to say this? How about: “The course thread included…” you can mention the 118 students later, probably not necessary until the results

“All thread content was developed” It seems as though you are going backwards at best or all over the place at worst. Reorder to state: Who developed thread content, how it was integrated (as lectures etc); and additional content (2 mandatory sessions; 2 community engagement sessions).

Interactive and community sessions: It is unclear how these matter to the focus of your paper. You say too little about their relevance. I would just mention them, maybe with the briefest possible mention in the context of the overall climate and equity intention of the course. All you need to say without getting into deep water is “Exhibits addressing the [physical and emotional?] impacts of climate change on affected communities were well-suited to provoking thoughtful discussions.”

Overall: consider what the reader needs to understand about the basic course structure and intent. In terms of all the details, the reader won’t have the same local resources you have; if they think they might be able to apply your approach to their own resources, they can contact you.

It’s unclear how beliefs about climate change are a ‘metareflective exercise of their learning.” The reader has no idea from this sentence what your goal is. Also if they were required to write this, how come they had the option to opt out? It sounds contradictory. Maybe: any student who did not choose to opt out was required…

p. 7 There seems to be an overlap between methods and results. Methods should state what the overall plan and process is. The results should state how many people participated, if any did not participate, and what was found.

Nothing is said about the thematic analysis itself and how it was conducted. See: Kiger ME, Varpio L. Thematic analysis of qualitative data: AMEE Guide No. 131. Med Teach. 2020;42(8):846-854.

7-8 “For instance, one student connected a lecture statistic regarding the nature of poor air quality ..with environmental pathology…” The reader is unlikely to understand what the actual insight here is, so I suggest finding a better, less obscure-sounding example

“…expand their medical knowledge…to include a critical review of the literature” It’s unclear how the above examples, which are pretty basic, show this. Wouldn’t students have heard in their sessions about the disparities mentioned in the quoted material?

9 ”…importance of hearing directly from affected communities” It’s unclear whether students were asking for such contacts, or whether in the course they had such contacts. Or were they responding to the museum exhibit?

Psychomotor: It’s unclear how much content in the teaching thread addressed actionable items

10 “Students participated in foundational lectures…on attitudes and beliefs” I feel that this should be embedded in the method section or tabulated in the results section. This is not the place to mention this as though it were some sort of concluding insight

“resulted in calls to action” There is a big difference between calls to action as expressed in an assigned essay vs in an activist format. “Students reflected in their essays on the different ways students could actively engage” seems more accurate. Better yet: “These activities ultimately led students to express a need for action and a desire to learn from the lived experience of patients affected by climate change. Through critical reflection…”

However, I don’t think you can claim that students generated a sense of personal & professional responsibility…etc. The more accurate claim would be that they expressed this sense.

It’s unclear to me how the CoP transformed the topic of climate change. Nothing you describe really supports this. And for whom do you mean? For the first year students or the CoP members? If the latter, you don’t show it in the paper. If the former, all we have is the claims in their essays. Maybe the students did express something like “This course really transformed my thinking” but you don’t provide evidence of that. If you mean the CoP members, we really don’t hear anything in this paper about the impact on them.

“Holistic educational approach towards addressing inequities…” This doesn’t seem to have been the goal of this paper as stated in the intro

“Didactics were augmented…etc” Why is this in the discussion? This seems like it should be in methods or not directly relevant to the paper.

p. 11 What are ‘unanimous reflections?” Do you mean, nearly all participants highlighted the impact the thread had in furthering reflection on the roles of privilege, responsibility and action?

Future Directions: Condense the first three sentences to ‘long-term impact’ on knowledge and action, as these plans seem unformed/speculative as yet

Adapting experiential community-based activities: I don’t know if the readers really understand what the authors did in their museum visits. The alternative suggestions are potentially great, but it’s not that easy for educators to adapt them, especially without knowing the details of what the specifics of such community exhibits are—not to mention in what context they could make demands of this sort on the curriculum. Maybe a Table detailing examples and specific, itemized suggestions would help

Reviewer #2: I commend the authors for their great work on addressing such a timely and relevant topic. Please see some suggestions below:

Minor grammatical suggestions: Add a comma in the first line of the abstract.

…impact on the environment and health, medical schools...

Page 1: Education on climate change’s affect (change to effect) on health...

Methods: How and why are 30 essays chosen for thematic analysis? Is 30 a representative number of essays here? Would suggest to add more information regarding this in the methods section.

Reviewer #3: 1.

General question -- The invitation from PLOS ONE reads as follows:

I am inviting you to peer review the following manuscript for PLOS ONE. In view of your expertise, I would greatly value your input on this manuscript’s suitability for publication.

Manuscript #: PONE-D-23-31947

Title: Fostering medical students’ critical consciousness on climate change, health, and equity

Authors: Andrew Muzyk; Trisha Dalapati; Sneha Mantri; Phillip Mitchell; Ian Allen George; Kathryn Andolsek; John Matthew Velkey; Jennifer Lawson

Article type: Research Article

So, why are you anonymizing the manuscript, e.g., Study authors XX and XX were responsible for the creation and implementation of the Climate Change, Health, and Equity thread in the first-year medical school pre-clerkship curriculum at the XXSOM and elsewhere. Makes the manuscript harder to read.

2. Table 1 provides a summary but no details regarding the cognitive, affective, and psychomotor domains and further classified according to the socio-ecological model for health promotion into individual, institutional/relationship, societal, and policy factors.

A. The manuscript itself should include quantitative data regarding frequencies.

B. Either the manuscript or an appendix should include actual examples that were interpreted according to the different categories.

3. What is the control? Are the students’ answers a consequence of the Climate Change, Health, and Equity thread in the first-year medical school pre-clerkship curriculum or would 2nd year or more advanced students who didn’t participate in the thread have provided similar answers?

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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Development of a curricular thread to foster medical students’ critical reflection and promote action on climate change, health, and equity

PONE-D-23-31947R1

Dear Dr. Muzyk,

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Kind regards,

Frederick Grinnell

Academic Editor

PLOS ONE

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