In the business world, there is a long history of companies faltering when their products do something different from what their customers really need. Customers don’t buy those products. Instead, they look around and find solutions that work for them – even when they were designed with a different purpose in mind. Think about how communication moved from phone to email to direct messaging on social media, or how people take allergy medicine to help them sleep. From the company perspective, you might think “that’s not what we meant this to do!” but from the customer’s perspective, you might hear “this does what I need!” This is the “Jobs to be Done” theory of consumer action, developed by Clay Christensen and colleagues at Harvard Business School.
In health professions education, we have a lot to learn from “Jobs to be Done.” We are often perplexed or disappointed when our learners choose to dedicate time to studying for standardized rather than spending additional time with patients or teams; or study more from commercial resources than from our institutional materials; or apply to more graduate training programs than our data suggests is appropriate. If we think about our learners’ “Jobs to be Done” we can understand these choices very easily… standardized tests often count more in grading and in selection for graduate training than clinical assessments, commercial resources are often more efficient in helping prepare for exams, and applying to more programs increases the odds of getting interview offers (to a point). Learners are behaving rationally.
So what do “Jobs to be Done” have to do with competency-based education? In designing curricula to prepare learners to work in health systems, how helpful would it be if we aligned training with the “Jobs to be Done?” We could develop clear, concrete descriptions of the jobs that learners need to do at each stage of their training. If we shared those “job descriptions” with one another, how much consistency would we find? How much local variability would we find? Could we agree on core responsibilities that, say, medical students on their initial clerkships ought to be able to take on? Or those that nursing students ought to be able to take on in the senior stages of their training? We could use those job descriptions to design fit-for-purpose assessments to assure readiness for progression.
Entrustable Professional Activities (EPAs) are one important effort to describe the jobs of trainees. In medical education in the United States, the Core Entrustable Professional Activities for Entering Residency were developed to describe those tasks that first-day resident ought to be able to perform with indirect supervision. In piloting these 13 EPAs, the Core EPA Pilot found that, in actuality, only subsets of these were adequately represented in medical students’ experiences and that there were gaps that would need to be filled if medical schools were to prepare their graduates to function according to this particular description of the jobs of the first day intern.
The fact that the Core EPA pilot identified gaps in training is not particularly surprising. On the whole, we aren’t used to thinking about the purpose of each stage of training being concretely tied to those responsibilities that learners will need to carry in the next stage of training. Rather, we often think of the many existing and idealized aspects of the profession and how to fit them into curricular time. For example, if we are serious about our learners being able to improve quality in our health systems, we can’t simply teach them the principles of quality improvement and assess them on theoretical quality improvement exercises, but we need to give them responsibilities as members of our actual quality improvement teams.
Are we brave enough to think humbly and simply and to rework our training to “just” prepare our learners to provide thoughtful, safe, and compassionate care according to their abilities at each stage of training? Can we trust that ambitious, creative, generative learners will each achieve excellence by contributing to innovation, discovery, and service according to their interests and passions and abilities? If we are compelled by the idea that learners will do the “Jobs to be Done” in their training, we can use our education resources more efficiently and equitably to help them all get there.
Doing this would also compel us to be vigilant in identifying how our learners’ jobs change over time with new models of healthcare delivery, with disruptions afforded by technology or world events, with societal shifts. Being vigilant, we would need to respond more nimbly to ensure that each of our learners is prepared to fulfill their responsibilities to their patients and teams with the appropriate supervision for their stage of training. Maybe our learners would have less cognitive dissonance and less of a need to diverge from our formal curricula to do their “Jobs to be Done.”
About the author: Jonathan Amiel, MD, is Professor of Psychiatry at Columbia University Medical Center, Senior Associate Dean for Innovation in Health Professions Education at Columbia University Vagelos College of Physicians & Surgeons and an Attending Psychiatrist at the New York State Psychiatric Institute and New York-Presbyterian Hospital.
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