It was low tide on the north shore of Boston when Steve Kearns felt the mosquito bite that would land him in a hospital with West Nile Virus disease for a week.
"For at least six months after that, I felt like every five minutes I was being run over by a truck," Kearns says. "I couldn't work, I couldn't walk very well and I couldn't focus. I wondered for a bit if I'd ever get better."
Kearns, 71, recounted the experience during a check-up with his physician, Dr. Gaurab Basu, and Dr. Charlotte Rastas, a third year resident in primary care at a Cambridge Health Alliance clinic in Somerville, Mass.
Basu had never seen West Nile in a patient before Kearns. The first reported case in Massachusetts was in 2002. By 2018, the year a mosquito bit Kearns, there were 49.
"When someone comes in with a fever and is confused, it's not what my mind thinks of as the diagnosis right away," Basu says. "This case has really taught me how much I need to be informed about the ways in which climate change is changing the patterns of infectious disease around the United States."
As Basu learned, rising temperatures offer longer breeding seasons for mosquitos, boost the virus replication rate, and make mosquitos more active. Basu now teaches about these and other effects of climate change in an elective course he offers residents. Residents in this course get more than 100 hours of advocacy training including how to speak and write publicly about the intersection of health and climate change.
He's part of a nascent effort to make sure climate change is part of the curriculum in hospital residency programs across the country. There's already a push, backed by the American Medical Association, to teach medical students about health risks tied to a warming planet. Now some doctors say that education should continue during residency, when doctors tailor what they've learned to a specialty.
"What a pediatrician needs to know about climate risk is not the same as what a surgeon needs to know, or what a radiologist needs to know," says Dr. Aaron Bernstein, interim director of the Center for Climate, Health and the Global Environment at Harvard's T.H. Chan School of Public Health.
There is no designated curricula for hospitals that want to teach emerging lung specialists about longer pollen seasons as temperatures rise or guide new emergency room physicians to consider water-borne diseases for patients with fever and diarrhea. But Bernstein and co-author, Dr. Rebecca Philipsborn, have published a framework hospitals can use as a starting point.
"At its heart, this is about preparing our resident physicians to provide the best care for patients and to safeguard health in our changing climate," says Philipsborn, an assistant professor of pediatrics at Emory University. "Patients want physicians to be able to provide guidance on things that affect their individual health. We have this accumulating body of evidence that climate change does just that. It changes what we see and it poses harms to our patients."
The framework has three parts: explaining the link between climate change and storms, fires, allergy seasons and other factors that affect health, suggesting ways doctors could adapt patient care in response to these changes, and preparing doctors for times climate change might interfere with care.
Rastas, who took Basu's elective course, says many residents seek such guidance.
"This is something that needs to be directly integrated into the curriculum," she says. "And [it] needs to become standard of practice because I think it's going to have such a huge impact on human health."
But some doctors worry about what will be left out of residency training to make room for climate change. Dr. Stanley Goldfarb, the former associate dean for curriculum at the University of Pennsylvania School of Medicine, says during the pandemic, for example, hospitals need to add training in intensive care medicine to more residency programs.
Goldfarb says hospitals should focus on training doctors, not advocates for social or political causes. He worries that discussing climate change with patients might create mistrust.
"There are concerns about getting into the political sphere," he says. "I'm against anything that's going to represent a barrier between patients and physicians being comfortable with each other."
But as wildfires sweep across Western states and hurricanes flood the Gulf Coast, other physicians are stepping up efforts to talk about the intersection of health and climate change.
"We want to impart this information to our residents as fast as we can because it's so important that they gain this information sooner rather than later," says Dr. Paul Dellaripa, one of the authors of a new climate change course for about 50 internal medicine residents at Brigham and Women's Hospital in Boston.
In part one, earlier this month, Dellaripa showed residents heat island maps of Boston that he reviewed to understand why a particular patient experienced kidney failure related to dehydration. Dellaripa adjusted the patient's meds and other care after realizing the patient lived in one of the city's hottest neighborhoods.
"There are tools out there that can help us identify areas of vulnerability in the Boston area," Dellaripa says. "If we can put those together with our patients we can better understand who's at risk for what and make the appropriate clinical adjustments."
Dr. Evan Shannon, a chief medical resident in internal medicine at Brigham, says Dellaripa's lecture highlighted ways rising temperatures have a greater impact on low-income, often minority communities. Shannon says racial justice and climate change "should be integral to medical education, it's an intersection that needs to be explored."
Dellaripa says he's talking to residency leaders in surgery and emergency medicine at Brigham about integrating climate change into their training programs in the coming months.
Advocates say including climate change in residency training won't stick until doctors are tested on these health effects before they're licensed to practice medicine.
In the meantime, there's growing interest in some unlikely places.
"What's further than what you might link to climate change than neurosurgery?" asks Dr. Ann-Christine Duhaime, the director of pediatric neurosurgery at Massachusetts General Hospital. "But I've been asked to give neurosurgery grand rounds on health and climate change, at three institutions, in the past year."
Duhaime talks about her plan to create a green children's hospital and about broader impacts of climate change on medicine. She says many surgeons are disturbed, for example, about the vast amounts of plastic and other waste generated in an operating room.
Duhaime says she's approached by many residents who are looking for guidance as well as information about their role with regard to climate change. Finding mentors and realizing there are steps they can take to address climate change in and outside the hospital helps, she says.
"They go into medicine because they want to help people, they see this looming threat, and the conflict between how they spend their days," she says, "and this whole climate change disaster — that conflict is really distressing to many of them."
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