Sustaining the planet by sustaining ourselves

Like many clinicians and scientists in the field of cancer, I entered medicine with a calling to serve. Medicine offered the opportunity to link my longstanding interests in science with actions that could benefit those in need.

After training in interventional radiology, I embarked on the first part of my career as a clinician-scientist who developed image-guided therapies for liver cancer. It was enormously fulfilling to build an NIH-funded laboratory that translated pre-clinical discoveries to patients with cancer. I learned by collaborating with oncologists and cancer scientists of all types. Plus, by training the next generation of interventional oncologists, I could scale my impact beyond the patients that I cared for directly.

After a dozen years in academia, I found myself taking more joy in the accomplishments of my trainees than in my own career. Furthermore, I felt that my impact had hit a steady state. Yes, I could continue to help cancer patients through my clinical practice, research, and teaching. But I would not dramatically alter my impact with the same portfolio of activities.

This recognition led to me to enter the second phase of my career: chair of a large academic radiology department. In this new role, I helped guide the care of patients across multiple hospitals, delivered resources to help other scientists succeed, and educated hundreds of trainees instead of dozens. As chair, I was thrilled to expand my impact in new ways, and to more people.

As it did for so many others, the pandemic changed everything for me. While locked down in April 2020, I realized my impact as a physician, scientist, and educator could be amplified by stepping beyond the confines of our medical center. Because of the uncertainties of COVID, all segments of society had an immense need for practical guidance.

Was it safe to go shopping? Was it OK for a 75-year-old grandmother with breast cancer to see her grandchildren? When could our children return to school in person?

These questions could not be answered with the randomized controlled trials so common to the world of oncology. Such data did not exist. At the same time, I saw the requirement for being “data-driven” as a handy excuse for inaction. According to Ipsos, physicians are the most trusted profession worldwide (https://www.ipsos.com/sites/default/files/ct/news/documents/2023-10/Ipsos-global-trustworthiness-index-2023.pdf), with scientists in second place and teachers third. As an academic clinician-scientist, I felt called to use that trust to guide my local community in their everyday decisions. By reaching out as a civic leader during COVID, I could impact every single person in my community, not just the patients seeking care.

Watching the ongoing health impact of wildfires, floods, droughts, and hurricanes, I realized that COVID was a laboratory for climate change. The wicked problems of the pandemic—restructuring society to be safe, health disparities for the vulnerable, especially those with cancer, and the barrage of mis- and dis-information—were being replayed with climate change on a multi-generation scale. And unlike with COVID, there was no vaccine for climate change.

I read deeply about the relationship of climate change to human health. As I reviewed the data, the link was undeniable. Fossil fuels were the predominant cause for the greenhouse gases causing climate change. Air pollution caused 8 M deaths excess deaths a year, and of these, 5 M were attributable to fossil fuels [1]. Extreme weather delayed access for cancer patients who needed treatment [2]. Cancer care through a sustainability lens had thus become important [3, 4].

As cancer physicians or scientists, we rely on data to make informed decisions. The data on climate change and human health were sobering. Just as oncologists cannot watch patients suffer without acting, I could not stand still as our planet’s health was being destroyed.

As a radiology chair, my personal challenge was how to blend my newfound interest in planetary health with my ongoing administrative duties. I needed to acquire a sizeable body of scientific knowledge and to build a network of collaborators. This would require protected time, preferably immersive and uninterrupted.

Over my career, I have spoken with colleagues who used sabbaticals to acquire new skills and integrate them into their careers. These discussions provided me two practical lessons: a) sabbaticals were uniformly cherished; and b) a department of the size and scope of radiology could not be run successfully with a chair in absentia. Thus, after a decade as chair of radiology, I took the leap to step away from my position.

In this perspective, I will share learnings from my sabbatical in sustainability. There are lessons to be gleaned for anyone considering a sabbatical. There are also clear benefits to our current and future patients when we take climate action. Lastly, I will share aspects of my current work and future plans.

Sabbaticals have a long and storied history, dating back to medieval Europe. Originally conceived as a period of religious reflection or pilgrimage, they gradually evolved into a practice designed to rejuvenate and inspire faculty members. By the 19th century, sabbaticals became more common in European universities. In the United States, they gained widespread popularity in the early 20th century, often tied to specific research projects or professional development goals.

Today, sabbaticals remain a valuable tool for faculty members to pursue new research directions, collaborate with colleagues from other institutions, or simply take a much-needed break.

Rigorous research on sabbaticals in medicine is surprisingly scant.

According to a 2019 survey of the Society for Human Resource Management, 11% of employers offer unpaid sabbaticals and 5% paid (https://www.shrm.org/topics-tools/news/benefits-compensation/sabbaticals-solution-to-employee-burnout). Data on the prevalence of sabbaticals within medicine compared with other fields is unclear. In a survey of 49 US medical schools from 2023, Robiner et al. [5] report that 26 (53%) contained faculty who took sabbaticals. At medical schools that offered them, an average of 2 faculty per year completed sabbaticals. While these numbers are small, they indicate that sabbaticals are possible in the right situation. Besides scattered and anecdotal case reports [6] (https://lombardi.georgetown.edu/lombardi-stories/a-sabbatical-just-what-the-doctor-ordered/), data for the prevalence of sabbaticals in cancer centers are not available. Furthermore, in a small-scale study at the University of Cambridge [7], quantifying the effects of sabbaticals on publication rates proved difficult.

As with oncology research, establishing clear goals and a rigorous process at the start is critical to ensure that a sabbatical is time well spent. Be forewarned: like when we age, time seems to accelerate during a sabbatical.

For my own sabbatical, I had three personal goals: a) to become a specialist in climate change and health; b) to conduct and publish planetary health-centered research; and c) to advocate for sustainability within and outside of medicine. We in oncology understand the importance of collaboration and rigorously seek it out. So too with my sabbatical, with the added dimension that I labeled my collaborative efforts as “customer discovery”. What did this mean? To seek out the unmet needs and challenges of those I interviewed.

Customer discovery is a form of research and education. It involves deep listening and empathizing with others, behaviors that oncologists and journalists perform every day in their practices. Akin to increasing our sample size for a clinical trial, I sought to interview as many folks as possible. I started broadly: speaking with chefs to CEOs, poets to politicians, and scientists to students. I took notes obsessively, collecting them on a spreadsheet. In my spreadsheet, I transcribed key points from each conversation and included a separate column for unmet needs.

After those unmet needs started to converge, I shifted to interviewing customers who had insights into those unmet needs: what solutions worked, and what had been tried before but failed. This approach is like recognizing how the needs of patients with cancer vary depending upon stage and diagnosis. For instance, to understand healthcare workforce challenges, I spoke with human resource specialists. To understand the business imperative for sustainability, I spoke with C-suite leaders, venture capitalists, and entrepreneurs. To understand how to communicate climate change effectively, I spoke with experts in rhetoric, storytelling, and behavior change. Eventually, I cataloged over 350 one-on-one interviews with individuals from across the world.

By writing, speaking, and traveling, I also built community. Part of my advocacy and learning involved giving dozens of local, regional, and international talks. Participating in global panels on sustainability became an easy way to reach larger audiences without travel—and to reduce my own greenhouse gas emissions.

Furthermore, I completed two sequential entrepreneurial certificates at Vanderbilt, launched a sustainable healthcare website called The Green Leap, and co-founded a non-profit called Greenwell Project.

Even if the privilege of taking a sabbatical is available, most of us in oncology will not take one. There are barriers at work, such as who will take care of our patients while we are gone and who will oversee our laboratories? And there are barriers at home, such as can we afford it and what about our spouses or family? There are also concerns that it might delay career progression.

These are legitimate concerns to be addressed on an individual and organizational basis. Not all sabbaticals need be a year in length; they can be shorter, and even measured in weeks instead of months. Through that lens, the opportunity to step away to learn something new may be more accessible than many have considered. Likewise, almost everyone changes jobs at some point. Transitions represent an opportune time to step away for additional time, a “mini-sabbatical”. Alternatively, instead of waiting to retire in graded or abrupt fashion, we can take a series of breaks within a career and work for longer before retiring. Rather than retirement, these breaks might be termed “rewirements”.

I am grateful to the hundreds of individuals and organizations who fueled my learning. In one year, I learned as much as I did during my first year of college or first year in medical school.

I will summarize my learnings into 5 takeaways, with suggested actions:

1. 1.

   The climate crisis is a communications crisis. In the United States, climate change is a deeply partisan issue, with the gap in partisanship increasing over the past decade. According to the Pew Research Center (https://www.pewresearch.org/short-reads/2023/08/09/what-the-data-says-about-americans-views-of-climate-change/), 78% of adult US Democrats consider global climate change as a major threat, while only 23% of Republicans do.

   Given that, our choice of words is immensely important when trying to nudge an audience into action. Accordingly, with general audiences, I avoid terms like “climate change”, “global warming”, “environmental”, and “justice”. Instead, I emphasize pollution, waste, and economics. Instead of fighting against climate change, I fight for planetary health.

   Because physicians are the #1 most trusted profession worldwide, we can be vital communicators of climate change by relating its impact on human health. We will also be more successful by using proven storytelling methods (https://commonslibrary.org/the-power-of-story-the-story-of-self-us-and-now/). Data alone will fail to inspire climate action at the speed and scale that’s required. The sooner we recognize this, the sooner we can help mitigate climate-induced wildfires, tick-borne illnesses, and extreme weather events.

2. 2.

   Sustainability is a new tool that addresses old problems. The adoption of sustainable practices into medicine will be as challenging as introducing any widespread innovation (such as developing new quality programs 25 years ago). Instead of considering sustainability as a standalone, I recommend embedding it into daily operations to address existing needs. In other words, consider sustainable medical practices as ways to reduce costs, improve quality, spark innovation, improve patient outcomes, and reduce inefficiencies.

   Another strategy is to embed sustainable actions together with new artificial intelligence (AI) tools. Working in parallel can facilitate more rapid adoption of sustainability and AI. Working in series will be more laborious, delaying potential benefits to those we serve.

3. 3.

   Tobacco and oil: different game, same playbook. The parallels between tobacco and oil are eerily similar. It took decades for medicine to accept tobacco caused a host of human diseases and societal ills. Although Big Tobacco was aware of these concerns, it successfully fought our efforts to curb smoking for decades by a) expressing doubt to the public (e.g. “if tobacco causes lung cancer, why do most people who smoke not get lung cancer?”) and b) having renowned scientists on their payrolls.

   Initially, Big Oil applied the same playbook to foment doubt that fossil fuels caused climate change. And now that the evidence is undeniable, the fossil fuel industry eagerly promotes technologies to curb carbon emissions that are decades away from adoption. It’s important that we in oncology be aware of these similarities and act faster than we did with tobacco. Not doing so will be the equivalent of overlooking the smoking habits of our patients. The sooner we act on fossil fuels, the healthier our patients, communities, and planet will be. To learn more, I suggest reading Merchants of Doubt by Naomi Oreskes and Erik Conway [8].

4. 4.

   Our current healthcare workforce is not sustainable. We have a looming workforce crisis as Baby Boomers retire, patient care needs increase, and more work cannot be extracted from healthcare workers. This situation has been called the “silver tsunami” and the “demographic drought” (https://hrtechedge.com/news/lightcast-report-warns-of-historic-u-s-labor-shortage-by-2032/). The sooner health systems recognize that this problem is not going away, the sooner we can explore innovative solutions to recruit more people into healthcare.

   Meanwhile, 37% of Generation Z members consider climate change as their top personal concern (https://www.pewresearch.org/science/2021/05/26/gen-z-millennials-stand-out-for-climate-change-activism-social-media-engagement-with-issue/), and 67% will choose to work for employers who show commitment to sustainability and reducing their climate impact [9]. Many of these individuals will seek climate-related careers in environmental law, engineering, non-profits, and policy. We might recruit entirely new people into healthcare by rebranding our profession as taking care of both patients and the planet. If we don’t shift healthcare to include the planet, we might miss top talent who instead choose careers outside of healthcare.

5. 5.

   The planet is our patient. The field of oncology understands ways to prevent cancer, the complex mechanisms which cause cancer, the complex systemic nature of cancer, and the side effects of our therapies. We can apply this experience to bring fresh perspectives to caring for the planet. For instance, in the climate world, reducing greenhouse gas emissions is termed “mitigation”, while building resilience to the untoward effects is called “adaptation”. Drawing parallels, we can consider climate mitigation as being like cancer prevention, and climate adaptation as being like cancer treatment. And as we know from oncology, prevention is preferable to the burdens of therapy.

As I have jumped headfirst into climate action, I consider myself part of a new breed of PCP: the planetary care physician. This type of physician understands that climate action must occur at the educational, research, operational, and advocacy levels.

From an educational perch, I enjoy showcasing sustainable healthcare blog posts, podcasts, and videos on my Green Leap website. Every month I also lecture on sustainability to a variety of organizations across the globe. For research, I’m part of a multi-disciplinary team that is conducting environmental life cycle analyses of radiology departments. Our first manuscript was recently published [10], and we are currently writing four additional ones. I’ve co-authored a state-of-the-art review of planetary health in radiology [11] and proposed a framework that extends the concept of translational research to include bedside-to-biosphere [12]. Operationally, I help institutions shift their use of iodinated contrast agent to a cheaper and less wasteful approach [13, 14] and to consider improved eco-design of their imaging units [15].

I’m also committed to climate advocacy through ongoing work at a host of medical societies. More recently, I helped found a nonprofit, Greenwell Project, where I serve as chief executive officer. Our mission is to design sustainable medicine together with patients. We have surveyed over 1500 patients on their attitudes to healthcare waste and pollution, and worked with 15 patient and family advisory councils across the United States. We aim to develop a cadre of thousands of patient advisors who can help hospitals and healthcare vendors design more sustainable products, services, and platforms.

Sustaining the planet starts with sustaining ourselves. After spending one-year on sabbatical, I highly recommend taking a break in our careers. Doing so will provide the time to recharge and to shift into new directions.

The responsibility of oncology to serve our patients applies to the planet too. After all, caring for the planet offers an untapped way to care for our patients.

Time and energy are our most precious resources, especially for those of us in oncology. By stewarding these resources, we can better care for ourselves, our patients, and our planet.

I now realize that Confucius was right. Do you?