Some Boston Doctors Bring Climate Change Into The Exam Room — Warily

It's a gray and chilly April afternoon when Michael Howard arrives for a checkup with his pulmonologist. But Howard is worried about what’s coming: the heat and humidity of a Boston summer.

"I lived in Florida for 14 years and I moved back because the humidity was just too much,” Howard says to physician Mary Rice, as he settles into an exam room chair at the Beth Israel Deaconess HealthCare clinic in Chelsea.

Howard, who is 57, has COPD, a progressive lung disease that can be exacerbated by heat and humidity. Even on this day, in a comfortable, climate-controlled room, his oxygen levels worry Rice. Howard agrees to try using portable oxygen. He and Rice take a slow walk around the clinic while Rice adjusts the levels.

Howard is resigned to wearing the clear plastic tubes looped over his ears and inserted in his nostrils. He assures Rice he has an air conditioner and will stay inside on really hot days. The doctor and patient agree that Howard should walk in the evenings to be sure that he gets exercise without overheating.

Then Howard turns to Rice with a question she didn't encounter in medical school: "Can I ask you, last summer, why was it so hot?"

Rice, who studies air pollution, is ready.

"The overall trend of the hotter summers that we’re seeing [is] due to climate change," Rice says, "and with the overall upward trend, we've got the consequences of climate change."

For Rice, connecting those consequences — heatwaves, more pollen, longer allergy seasons — to her patients' health is becoming routine. She is among a very small but growing number of doctors and nurses who discuss those connections with patients, in the exam room.

They can point to the World Health Organization, which calls climate change "the greatest health challenge of the 21st century," and a dozen U.S. medical societies that urge action to limit global warming. But none of those societies have guidelines that explain how providers should talk to patients about climate change. There is no list of "dos" — as in wear a seat belt, use sunscreen, and get exercise — or "don'ts" — as in smoke, drink too much or text while driving.

Climate change is different, says Rice, because an individual patient can't prevent it. So Rice focuses on steps her patients can take to cope with the consequences of heatwaves, more potent pollen and a longer allergy season.

'A Difficult Conversation'

That's Mary Heafy's main complaint. The 64-year-old has asthma that is worse during the allergy season. On this day, Heafy has come to discuss whether she's on the right medications. But she also wants to know why her eyes and nose are running and her chest is tight for longer periods every year.

"It feels like once [the allergy season] starts in the springtime, it doesn’t end until there’s a killing frost," Heafy tells Rice, with some exasperation.

"Yes," Rice nods, "because of global warming, the plants are flowering earlier in the spring. After hot summers, the trees are releasing more pollen the following season. And the ragweed, it’s extending longer into the fall."

So Heafy may need stronger medicines and more air filters, and may spend more days wearing a mask, although the effort of breathing through a mask is hard on her lungs as well.

Heafy tells Rice she’s grateful for the information and prevention planning.

"I can do a better job taking care of my own well-being," Heafy says as she and Rice finalize a prescription plan. "Physicians talk about things like smoking, but I don’t know that every physician talks about the environmental impact."

There are many reasons few do. Besides the lack of guidelines, doctors say they don't have time during a 15- to 20-minute visit to approach something as complicated as climate change. And the topic can be controversial: While a recent Pew Research Center poll found that 59% of Americans think climate change affects their local community "a great deal or some," only 31% say it affects them personally, and views vary widely by political party. Some doctors worry about challenging a patient’s beliefs on the sometimes-fraught topic, says Nitin Damle, past president of the American College of Physicians.

"It’s a difficult conversation to have," says Damle, who practices internal medicine in Wakefield, Rhode Island. "Many people still think it’s something they’re not going to be affected by, but it’s really not true."

Damle says he "takes the temperature" of patients with some general questions about the environment or the weather before deciding if he'll suggest that climate change is affecting their health.

Gaurab Basu, a primary care physician at Cambridge Health Alliance, says he’s ready if patients want to talk about climate change, but he doesn’t bring it up. Basu says he must make sure patients feel safe in the exam room. Raising a controversial political issue might erode that feeling. When patients do ask about climate change, he says it can be "a difficult conversation."

"The hard thing about this is to articulate the risk does elicit a lot of reasonable and rationale concern," Basu says. "I have to be honest about the science and the threat that is there, and it is quite alarming."

So alarming that Basu says he often refers patients to counseling. Psychiatrists concerned about the effects of climate change on mental health say there are no standards of care in their profession yet. They suggest a response must be tailored for each patient, but some common responses are emerging.

'We Are Hungry For Information'

One environmental group isn’t waiting for doctors and nurses to figure how to talk to patients about climate change.

"We're trying to create a demand for these conversations to get started," says Molly Rauch, the public health policy director with Moms Clean Air Force, a project of the Environmental Defense Fund.

Rauch urges the group's more than 1 million members to ask doctors and nurses for guidance. For example: When should parents keep children indoors because the outdoor air is too dirty?

"This isn’t too scary for us to hear about; we are hungry for information about this, we want to know," Rauch says.

But Rauch says it doesn't seem like climate change is breaking into the medical community as a health issue, and few nursing and medical school offer classes on climate change.

One study found classes about environmental health or global warming at 20 out of 140 U.S. medical schools. Study co-author Arianne Teherani says medical schools are struggling to decide what students need to learn in the classroom as technology and medicine advances, and what they can learn on their own. Introducing climate change is difficult because few students have environmental science classes in high school or college.

And in the meantime, "the world is changing much more rapidly, the number of California wildfires has gone up, and all sorts of other weather-related calamities have increased," says Teherani, a professor at the University of California San Francisco School of Medicine.

Teherani says questions about a patient's environment should be part of the emergency room intake and their medical history to help diagnose and treat some ailments.

A few nursing schools are adding climate-related courses to their training to prepare students for conversations with patients.

"Nurses need to catch up quickly," says Patrice Nicholas, director of the Center for Climate Change, Climate Justice and Health at the MGH Institute of Health Professions.

Nicholas attributes the delay, in part, to politics. "Climate change really needs to be reframed as a public health issue," Nicholas says.

The few doctors and nurses who have started discussing climate change with their patients say they've not had resistance from patients or industry groups yet. But that may be because the idea of bringing climate change into the exam room is not something most providers have begun to consider.