Will Patients Listen If Health Care Providers Talk Climate Change?

Recently I had the chance to join @chcradio, the Conversations on Health Care radio show that features in-depth discussions on health policy, co-hosted by Mark Masselli and Margaret Flinter and produced by Adam Shapiro. Our episode, Will Patients Listen If Health Care Providers Talk Climate Change? is live here

One of the big insights I’ve learned and shared on the podcast is the role of healthcare professionals in educating their patients about the effects of climate change on health. Andrew Lewandowski, a private practice pediatrician in Madison, Wisconsin, did this in over 200 well-child visits and published his results in this journal article.

In his private practice, Dr. Lewandowski followed the American Academy of Pediatrics recommendations (more on these below) and read the following 45 sec script during over 200 well-child visits in late 2020:

"In the last two years, the American Academy of Pediatrics and 100 other health organizations declared climate change a health emergency. Air pollution alone caused over 64,000 premature deaths in the United States in 2016, and worsening air quality is only 1 out of 9 ways that climate change is harming people, disproportionately harming children. So just like I want your children to eat healthy foods and be in the right car seat for their health and safety, we now know that decreasing our energy use, increasing energy efficiency, and supporting clean energy initiatives are also important for improving our children's health. Any questions?”

Then he surveyed his patients afterwards. This 45 sec script seem to have made a strong impression. Here are his results:

First he asked what they knew before the visit. Of the 133 who responded, 82% reported prior awareness of health harms from climate change (90% of self-reported liberals and 57% of self-reported conservatives). When asked if they learned more about health harms from climate change during the clinic visit, 89% said yes (88% of liberals, 86% of conservatives). Additionally, Dr. Lewandowski asked about the likelihood of changing energy use behaviors and reported that 89% said they were likely or very likely (93% of liberals, 79% of conservatives) to do so, and 91% were likely or very likely to support clean energy initiatives (95% liberals, 72% of conservatives).

On the Zoom call I joined, Dr. Lewandowski pointed out that none of his patients complained about his use of time in the appointment to talk about this topic, and none of his patients have left his practice.

This experiment and practice of discussing climate change during a doctor-patient visit may strike you as bold, and possibly even beyond the scope of routine care, if you didn’t know that the American Academy of Pediatrics (representing 67,000 pediatricians) began recommending as early as November 2007 (and updated in 2015 policy statement) that pediatric healthcare professionals play a vital role in integrating sustainability into their thinking about health. Many professional associations have followed suit, including the American Medical Association. The National Academy of Medicine, of which I’m a proud member, has taken a leadership role in bringing together an Action Collaborative on Decarbonizing the U.S. Health Sector.

This role of health care professionals, especially doctors, coincides with a high degree of trust that the public tends to put in us. Above is yet another poll that reaffirms that public confidence. Regardless of our political positions, we all want the air that we and our families breathe to be clean, the water to be drinkable, and to take special care of our more vulnerable seniors, pregnant mothers, and babies, and others. Making sure that people understand the relationship between the environment and their health is a vital responsibility of all physicians, in the clinic, and as members of our communities.

I learned about Dr. Lewandowski’s work at an online meeting of the New Hampshire Healthcare Workers for Climate Action meeting, which was co-sponsored by the Medical Society Consortium, a collection of professional medical associations working at the national and state level on the environmental impacts on health and of health care.

If you’re a physician and want to get involved, check out the Consortium website and consider signing up! If nothing else, it’s a great opportunity to learn more and get to know some great people who feel passionately about making healthcare healthier.

Bring Out Those N95/KF94 Masks Again

As we enter into another summer of record-setting heat, drought-exacerbated fires are causing more air quality issues again. This time the Canadian fires are affecting everyone from those across Canada to much of the eastern part of the US. (On the left is a gif from the CBC)

There’s some great advice about how to protect you and your loved ones in many articles, like here and here. My favorite recommendations are:

• Listen to your body (take it easy)

• Drink lots of water

• Wear a well-fitting mask (right sized KF94’s for kids if you can get them)

• Consider an air filter with HEPA filters.

There are three additional points I wanted to share, two about the effects of bad air quality on our brains and behavior, and one practical tip —don't make it worse by generating any more bad air in your own kitchens! Here’s what I mean:

• Really protect your young children and pregnant moms: Beyond the harmful effects of bad air quality we already know about like asthma, this study added to the evidence that bad air is harmful to the developing brains of babies in utero and young children. For pregnant women in the first trimester, higher exposures to bad air (NO2 or PM2.5) were associated with more behavioral problems in their 4-6 year olds (especially girls). Also, the researchers found that kids aged 2-4 yrs exposed consistently to bad air quality showed both more behavioral problems and lower IQ when they were 4 - 6 yrs. Here is a sentence from their Results:

“For postnatal exposures, each 2 ug/m3 increase in PM2.5 (particulate matter) at age 2-4 yr was associated with a 3.59 unit higher Total Problems score and a 2.63 point lower child IQ.”

— Yu Ni et al Environmental Health Perspectives 2022

• The cognitive effects of bad air are especially bad for seniors (possibly men worse than women): This study in China published in the eminent journal, PNAS, looked at standardized verbal and math test performance compared against air quality and found that people exposed to worse air (for longer durations) did worse. And the effect was especially pronounced for men over 64 with lower educational backgrounds. A scientist cited in this article in the Guardian newspaper interpreted the results as showing that people lost a few years of education with the long term exposure to bad air. The effect was mostly in verbal skills, not math.

• Don’t make it worse inside by frying or broiling or stir-frying and if you do, USE your fume extractor fan. While tobacco smoke is a common cause of lung cancer, many people, especially women, can develop lung cancer without ever having smoked, especially a type of cancer called adenocarcinoma. This study from Taiwan published in the top journal, Nature, looked at whether this might be because these women were exposed to oil fumes from cooking (especially stir-frying with smoldering hot oil). They found a strong connection—more exposure to cooking fumes, higher risk of lung cancer. The good news? Using a fume extractor reduced the risk by 50%.

Stay Safe!

In the Spirit of New Beginnings: A Few Words of Advice

Recently I was delighted to help launch a new Women’s Employee Resource Group (ERG) at Boston Children’s Hospital. It happened to occur within a few days of a second momentous occasion for me personally—the graduation of our oldest child from college. We refer to our graduation ceremonies as commencements, because, in fact, they are about new beginnings. Something about beginnings seems to inspire speakers to give advice. I’m no different. I thought I would help launch of this new employee resource group with a few of my own life lessons with the hope that they might offer some ideas for how women, and champions of women, can make the most of this new resource at BCH:

(1) Know Thyself

It really helps to know your own strengths and weaknesses. In one of the career development workshops we hosted for junior faculty and administrators when I was Chief Scientific Officer at NYU, we offered people the chance to complete personality tests like Myers-Briggs or conflict styles or StrengthsFinder tests. And if you really want to know yourself, ask others for input, like a “360” (where colleagues, direct reports, and bosses evaluate your strengths and your opportunities for growth), and then be ready to hear the praise and criticisms.

Understanding your personality type means you can try to grow and extend beyond your natural tendencies. For example, despite being an introvert, I took on roles that required frequent public speaking, cocktail parties, and even after-dinner talks. As a colleague put it—you just have to reserve some time after these events to go into your “she-cave.”

People can grow—I really believe that— but under stress, it’s easy to revert. The best protection comes from the people you work alongside. For example, I have been guided by some amazing people, who more than once, offered invaluable advice. “Consider dropping this person a note” or “Have a quiet check-in with that person and hear out their concerns.” Surrounding yourself with people who have superpowers where you have blindspots.

(2) Believe in Yourself and Support Others

It’s so vital to have confidence in yourself—and even easier if you have trusted colleagues who will keep you out of trouble. In a New York Times Corner Office interview I told the story of how I was once counseled not to consult with others so much in my decision making process—“you should tell them what to do, not ask them!” Of course I disagreed. My consultative approach was who I was.

Just as important as believing in yourself is to remember to support others. Think about how you can create a nurturing and open environment for everyone to flourish. It’s tough to lead, so help others be successful. A few years ago a group of women leaders (Women of Impact) pooled our collective experiences and wrote about best practices we had observed for creating a supportive, inclusive environment. It’s still one of my favorite publications (and here’s a handy infographic courtesy of Della Lin, MD).

(3) Keep Growing Together

As someone with deep academic roots, I’m biased towards lifelong learning. For me, that includes reading (libraries are the best) and listening to podcasts. Topics that really helped me grow include: women in the workplace, communications, negotiations, time management, motivating others (very handy with the kids too), leadership (mostly through countless great biographies), managing as an introvert, and lots of great science and climate change books. I’ll highlight some of my favorite recent reads/listens in a posting soon.

Whether in an ERG or outside of work, think about the topics you’d like to learn more about, the skills you’d like to grow. In a previous role, we created monthly gatherings that included sessions like how to be a great mentee, speed mentoring, and negotiations.

What’s even better than growing is growing together.

Switching Anesthetic Gases to Go Green

In conversations with people in health care about climate change, I hear a frequent refrain—

What can I do? How can my health system or hospital or practice make a difference?

Our emissions in health care are unnecessarily high—the health damage from pollutants that come out of health care itself are commensurate with the 44,000 - 98,000 deaths in hospitals resulting from medical errors (according to Matthew Eckelman and Jodi Sherman in their PLOS ONE article)

Let's start there: let's lower our own carbon footprint.

Today I’ll share one opportunity that many systems are pursuing, and that is lowering the significant emissions associated with anesthetic gases. Most inhaled anesthetic gases are unmetabolized and end up vented straight into the atmosphere. Many are greenhouse gases (like hydrofluorocarbons) that are even worse than carbon dioxide in terms of their ability to trap heat in our atmosphere, much much worse.

A quick review CO2 equivalents from our publication in NEJM Catalyst.

"Measurements of carbon footprint or emissions are most commonly reported in terms of CO2 and carbon dioxide equivalents (CO2e). CO2e is calculated by using the global warming potential of 1 ton of a gas relative to 1 ton of CO2 over a given period of time (typically 100 years). For example, 1 ton of the general anesthetic desflurane is equivalent to 2,540 tons of CO2; 1 ton of
a similar anesthetic, sevoflurane, corresponds to 130 tons of CO2.6 As a point of reference, on average, a gasoline-powered car emits 1 ton of CO2 per 2,500 miles driven — about the distance from Boston to Salt Lake City."

(Want a quick primer on #decarbonizinghealthcare? Check out this LinkedIn article)

Desflurane and sevoflurane are commonly used anesthetics that are released into the atmosphere. Anesthesiologists tell me that they are virtually interchangeable in clinical practice. Moving from desflurane to sevoflurane can save a hospital money AND significantly reduce the carbon emissions. Leana Wen M.D. M.Sc. Wen wrote an informative editorial in The Washington Post and talked with several systems, including Ascension and Virginia Mason Hospital and Seattle Medical Center about their successes switching off desflurane, and experts like Emily (Emmie) Mediate at Health Care Without Harm.

Besides switching to sevoflurane, we can do even better, we can use LESS sevoflurane, because even it has a very high environmental impact. Just out is an article published in the American Society of Anesthesiologists Monitor that points out that instead of pumping out higher than necessary flows of these gases, lower “fresh gas flow (FGF)” rates of less than 1 L/min provide effective anesthesia and lower pollution. They blame the waste on the outdated sevoflurane FDA package insert (that suggests higher FGF rates, despite the literature to the contrary).

The authors, Seema Gandhi (University of California, San Francisco), Jeffrey Feldman, Lauren Berkow, and Jodi Sherman, also point out that lowering FGF saves health system and our health care system. The two research studies they cite show that University of Washington Medical Center and UCSF saved over $100,000 per year by alerting their anesthesiologists when FGFs exceed a set threshold. (This research was sponsored, in part, by The Commonwealth Fund.)

In the UK, where the National Health Service announced in 2020 that their entire country’s health system would be net zero by 2040-2045, the entire nation will have stopped the use of desflurane outright by 2024. The Royal College of Anaesthetists and the Association of Anaesthetists fully support this.They figured that anesthetic gases contributed 2% to the overall carbon footprint of their health system. Here’s what their Chief Sustainability Officer, Nick Watts, says will be the effect:

“Stopping the use of desflurane across the NHS, with use allowed only in exceptional clinical circumstances, will further reduce harmful emissions by around 40 kilotonnes of carbon a year – the same as powering 11,000 homes every year.”

Already the use has dropped from 20% of all anesthetic gases to 3%. The NHS is well on their way. Read more of what Watts has to say here.

So the next time you wonder what we can do to combat climate change--think about the operating room.

Ask your teams what they are doing to use lower emissions (and lower cost) anesthetic gases? Have they switched away from desflurane? And for all their inhaled anesthetics, are they using the lowest flow rates necessary for effective anesthesia?

And if so, GREAT JOB!

#climatechange, #netzero, #healthcaresafety, #healthcare, #anesthesiology