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Am Fam Physician. 2021;104(5):526-530

Author disclosure: No relevant financial affiliations.

Case Scenario

I have a patient, K.B., with a three-year history of asthma. The patient's parent is concerned because K.B. wakes every night coughing. The family just moved to an apartment that does not have air conditioning and has received several code violations for a leaking roof and windows. The apartment is located next to two major interstate highways and is 10 miles from a cement factory. Air quality has reached the orange zone several times this month, and pollen levels have been consistently high for several months. I have provided the parent with an Asthma Action Plan and updated K.B.'s medications according to current guidelines. I believe that the environmental factors exacerbate or even cause my patient's condition, so how do I talk with the family about these issues over which they have little or no control? How do I talk with a patient about issues such as air pollution or climate change and their impacts on health?

Commentary

This case provides an example of how the environment can have significant impacts on the health of our patients. It also illustrates the complex interaction of local, regional, and global environmental harms. The wide scope of environmental threats to human health presents challenges in managing patients who are increasingly affected by climate-related changes, including severe weather events, extreme heat, worsening air quality, increasing allergens, changes in vector ecology, water quality, food and water supply, and environmental degradation.1

The effects of climate change on individual and entire population health are well established.2,3 Many of these effects, especially those related to disruption of infrastructure, heat, and air pollution, are regional.4 Health harms disproportionately affect children, pregnant people, older adults, and those with limited resources and/or populations who are marginalized who have been disproportionately exposed to unhealthy environments due to a history of discriminatory policies. When wondering whether and how these health impacts should be discussed with a patient, physicians should be knowledgeable about the daily life and circumstances of the patient and trust that patients recognize their family physicians as credible sources of information and support.

GENERAL CONSIDERATIONS BEFORE INITIATING DISCUSSIONS

Although only limited evidence is available to guide clinicians on broaching discussions about climate change with patients, it can be helpful to remember that health care professionals, including physicians and nurses, have powerful voices and are among the most trusted individuals according to populations surveyed in the United States.5,6 Physicians also have an ethical obligation to discuss climate concerns with their patients7 because climate change has been determined as a health emergency and is identified as the greatest public health threat of our century.8,9 Finally, physicians hesitant to provide advice about environment and health should take solace from data showing that more than three-fourths of the U.S. adult population would support climate solutions if they benefited personal or public health.10,11 A patient-centered approach to such discussions addresses patients' specific health concerns while exploring their receptivity to a larger, climate-informed treatment plan. Table 1 suggests approaches to common physician concerns about conducting climate change conversations in the office setting.1,3,1217

Practical concernsCounseling considerations
How does climate change impact the health of my patients?The health effects of climate change are well documented on the Centers for Disease Control and Prevention and World Health Organization websites1,12; in a report created by the Medical Society Consortium on Climate and Health13; and by summary reports published in The Lancet, Annals of Internal Medicine, and Pediatrics.3,14,15
Do I have enough time to incorporate one more topic into my visits?Physicians should prioritize which patient counseling topics to address and how to address them effectively and efficiently for each patient. Physicians should seek resources and determine the best ways to incorporate priority topic(s) into well-visit and problem-visit workflows. Consistent, simple, clear, and tailored messaging is recommended.16 Counseling generally should be brief (less than one minute) to improve patient receptivity.
Reimbursement and federal standardsAlthough no International Classification of Diseases-10 (ICD-10) codes currently reimburse for environmental justice–related activities, experts are currently working with federal leaders to incorporate the topic into the Centers for Medicare and Medicaid Services standards. This may ultimately influence reimbursement by other payors, quality assurance standards, and health systems rankings. Consistent shorter messaging is likely to be more effective than attempting to meet reimbursement criteria for time spent counseling.
This topic is too controversial, and/or I do not have support from my peers and patientsMultiple organizations, including the American Academy of Family Physicians, American College of Physicians, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and American Psychological Association, support health care professionals and leaders as they work to address climate change locally and nationally.17
Physicians are already tasked with making difficult and potentially controversial health recommendations with which colleagues and patients sometimes disagree. Pediatric clinic data suggest that the risk of a negative patient response is exceptionally low (eTable A). Physicians have an obligation to communicate concern for the patient's health and to focus on the best possible outcomes.

MAKING RELEVANT HEALTH RECOMMENDATIONS

A useful starting point for health care professionals wanting to familiarize themselves with key components of successful climate health messaging is found in ecoAmerica's communication guide.18 The guide provides specific examples of language to use when discussing the health impacts of fossil fuel–driven pollution and climate change. It recommends using positive and locally focused phrasing (“protect our families” rather than “stop climate change”) and offers key talking points, such as, “I'm a health professional because I care about the health of everyone in our community.”18

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Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous. Send scenarios to afpjournal@aafp.org. Materials are edited to retain confidentiality.

This series is coordinated by Caroline Wellbery, MD, associate deputy editor.

A collection of Curbside Consultation published in AFP is available at https://www.aafp.org/afp/curbside.

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