title: What do tomorrow's doctors need to learn about ecosystems? - A BEME Systematic Review: BEME Guide No. 36.
abstract: BACKGROUND
  Human health is fundamentally determined by the health of ecosystems. Guidance is lacking about how to address the topic of ecosystems within medical education.
  
  
  OBJECTIVE
  To determine the nature of discussions around ecosystems in the educational, medical and medical education literature. To identify learning needs of tomorrow's doctors.
  
  
  METHODS
  A narrative synthesis approach was used. Systematic searches were completed in 14 databases. Two independent reviewers screened results. Preliminary synthesis included textual descriptions and quality appraisal. Data were analysed using the Education for Sustainable Healthcare framework and thematic analysis. Relationships between studies were explored. Best evidence synthesis, contacting authors of primary studies and critical reflection reinforced robustness.
  
  
  RESULTS
  Six thousand seven hundred and fifty-three abstracts and 123 full texts were screened. Twenty-seven studies were included. Many studies lacked clear reporting. Medical students and doctors displayed knowledge about ecosystems, but lacked confidence to enact sustainable practices. Education about causes and consequences of environmental change is required. Few studies proposed specific learning objectives.
  
  
  CONCLUSIONS
  To prepare for roles as health care workers and leaders, medical students must learn about relationships between ecosystems, health and health care. The Education for Sustainable Healthcare framework outlines essential knowledge and attitudes but requires addition of practical competencies. Further research should explore the framework's relevance in different contexts, in order to structure training accordingly.
authors.affiliation: a Hull York Medical School , York University , UK .
authors.forename: Sarah Catherine
authors.initials: SC
authors.lastname: Walpole
authors.affiliation: a Hull York Medical School , York University , UK .
authors.forename: David
authors.initials: D
authors.lastname: Pearson
authors.affiliation: a Hull York Medical School , York University , UK .
authors.forename: Jonathan
authors.initials: J
authors.lastname: Coad
authors.affiliation: b Norwich Medical School , University of East Anglia , UK.
authors.forename: Stefi
authors.initials: S
authors.lastname: Barna
mesh_terms: D017753:Ecosystem; D004501:Education, Medical