Discover Your Unique Way of Learning - Dr. Rivka Stone, Chief Medical Officer at Med School Tutors

DR. RISHI DESAI: Hi, I'm Rishi Desai. In addition to all the challenges medical students and residents have faced throughout COVID, it's also been a bit of relief in the form of major changes to medical licensing exams. We're going to talk about this important aspect of medical education on today's show with Dr. Rivka Stone, an assistant professor at the University of Miami Miller School of Medicine and the Chief Medical Officer at Med School Tutors. Thank you so much for being with us today.

DR. STONE : Thank you so much for having me. 

DR. DESAI: I'd like to start out with just learning about your own background. What got you started in medicine, and specifically, dermatology?

DR. STONE: I really always wanted to be a doctor. My parents like to say that it's because they bought me a Fisher-Price doctor kit has a young child and the rest is history. But I really think that it's a reflection of who I am. I'm a thinker. I love science. I really enjoy connecting with and helping people, and I always felt that medicine would be a perfect fit for me. What I came to discover later was that I also have a passion for research, which is something I only realized through an internship that I did at a pharma company, developing cancer therapies when I was an undergrad. That's what really spurred me to pursue the dual MD–PhD degree to become not just a physician, but a physician-scientist, and that kind of changed my perspective. 

But as I went through my clinical rotations, I found myself, not simply thinking, “Do I like what doctors do in this field?” but also just as critically, “How will this work, practically? Patients will come to me for help, and treating them will inspire me to do the research, but will I also actually be able to do it in a high-quality way, in a field that may directly improve the lives of patients?” 

When I got to dermatology, I knew I'd kind of found my answer there. I really love the pace and the variety of clinical dermatology where you see patients of all ages. Really we have a host of medical and procedural tools to help us best we can. So, from a very practical perspective, it also helps to have access to the skin, like with minimally invasive biopsies, to do translational research, and that actually yields new treatments. In that way I'm really fortunate that dermatology found me. 

DR. DESAI: I'm curious. I feel like with dermatology specifically, there are so many myths, especially in the general public, about what that means, and what that lifestyle must be like. What are some things that you hear, that as an actual practicing dermatologist, are just not true?

DR. STONE: I hear a lot about how dermatology is just pimples. Either that, or I hear a lot of, “It's just Botox and cosmetics, and just aesthetically-driven kind of practice,” and that it's very cush, it's very easy. It couldn't be further than the truth. Certainly, the one thing that's nice about dermatology is you really have a variety of options within the field to focus on what really interests you. But we see so many patients, especially in the academic setting, that really need help. They're suffering tremendously from their skin diseases. Their quality of life is impacted and you really have a chance to come in and sometimes even the diagnosis that you're making that others have been stumped on. In that way, I think that to say that the field is not really a doctor—that you're not really doctor dermatologist, is really selling the field short and also the opportunity to change the lives of patients. 

DR. DESAI: Yes, that makes a lot of sense. When I started out in medical school, I was also very interested in dermatology, and so, I got a kind of first-hand look at it, and definitely changed my view of the of the field as I got to get to know it better. You also, of course, in addition, to passion around research in derm, you got involved with tutoring, and and then it progressed into Med School Tutors. Do you mind talking about that nine-year journey? What has that been like? 

DR. STONE: Absolutely. It was actually longer than a nine-year journey in the end, because teaching, in one form or another, is something that's really accompanied me all along the way. After high school, I actually spent a year receiving a formal teaching certification and I taught chemistry and calculus in private school in a high school in addition to tutoring some middle school students while I was in college. But when I entered medical school, I participated in a peer mentor tutor program. I was at Rutgers New Jersey Medical School, and I continued to tutor medical students for the USMLE exams especially during my research years. 

For my PhD, when I was in the lab, I had a little bit more free time, and I actually heard about Med School Tutors from a fellow MD–PhD student and I started as a tutor for MST when I was in my fourth year of medical school. Originally, it was just a good way to stay on top of the basic sciences, while also making a little bit extra on the side. But gradually, I really came to appreciate the profound significance that there was in the relationships that I was building with the students that I was working with, and these were students across the globe. 

So after some time doing just a standard one-to-one tutoring, I was invited to join MST's tutor development team to train and mentor fellow tutors. I ended up leading several larger content development projects while I was in my dermatology residency. Over time, I was offered the position of Chief Medical Officer in 2018, and now, I'm really privileged to lead a really amazing team of over 150 tutors, who are accomplished. They're educators. Not only have they excelled in their boards, but they come to us with this impressive list of accomplishments, both in the teaching and education realms. So, really lucky to be in this position.

DR. DESAI: I want to underline something you said, just very quickly in passing, in case people missed it. You tutored in chemistry and in calculus. That's what you said, right? 

DR. STONE: I taught high school, yes. 

DR. DESAI: Which arguably, I think, are two of the scariest fields for most folks. Certainly for me personally, those were two very challenging topics, and so I give you huge kudos for tackling them and mastering them to the level of teaching. But what I want to ask was, give a bit of an overview of Med School Tutors. What's the philosophy? How does it differ from other approaches to test prep? Because a lot of folks are trying to get through these exams. What do you do differently to help them accomplish that?

DR. STONE: Med School Tutors really specialize in one-to-one tutoring. What that really means is the human-to-human approach to helping, whether it's pre-meds, medical students, or residents, now, even more recently, succeed. MST was founded back in 2007 and just over the past 14 years or so we've worked with thousands of students from nearly every medical school not only in the US but really throughout the rest of the world. It's pretty incredible. As a result, we have accumulated this huge mass of data and knowledge that gives us its insight into the students that come to us for help. In the end, what that looks like is that our pairing process, which is the daily meeting that we have where we discuss each new student and match them with an appropriate tutor, it really makes sure that the student has a tutor who's a right fit for them, and supports them during the very stressful preparation period for the exam that they're taking. 

One big of aspect of MST that really sets us apart I think from others is our tutor selection and training process, which I've already kind of alluded to. But to begin, our tutors come to us. They're very strong already in content obviously, but they're also strong in process. Not only have they scored very highly on the exams that they're tutoring for, but they also teach. They're able to teach the practical skills of creating a study schedule, understanding how to use the other resources that are out there effectively, whether it's how to use Q-Banks and get the most out of them, even just how to select them among the hundreds of resources that are out there for each exam, which can be so overwhelming for students. 

Each new tutor that we bring on is actually trained by a mentor, who is a senior MST tutor who on boards them goes over the processes and the philosophy of the company, gives them feedback on their mock tutoring session, which is actually session that each new tutor does with an actor who's posing as a medical student and that's reviewed thoroughly and comprehensively with the mentor. Then as the tutor get started in the company, the mentor will oversee their work very closely with the first couple of students and then more from a distance as they gain more experience with the MST framework. 

Tutors really love this relationship that they have with their mentor. They use it not only for their work with MST, but also outside of MST, for professional development. They know that they can come to their mentor whenever situations come up, either with circumstances, or student situations that occasionally arise. The tutors are really given constructive feedback from the entire team as part of scheduled performance reviews, and they have the opportunity also, as they continue on in the company, as I did, to take more leadership roles over time. That's very empowering for them, and something that's uniquely something that they get from their work with the company. 

So, at least for the student's end, we like to tell our students that they get not only their one individual one-to-one tutor, but they're actually getting the collective knowledge and wisdom, experience, of MST's entire tutoring team that's supporting their success. In fact, we've had a number of times that some of our top tutors are former MST students who came to us for help, did exceptionally well on their exams, and they came back to tutor future students in a similar way. There's really nothing like that shared experience. 

DR. DESAI: It's pretty impressive. As you describe this process, it's a pretty rigorous system that you've put into place. I'm just curious: a) What inspired that that framework, with folks doing role-plays and watching and giving feedback? and tied to that, b) Are you personally familiar with any university that offers that same level of rigor for teachers going through? If so, tell me about that, because I'm not. I've never even heard of a place that does that level of rigor in their training, so I'm just curious if you've come across them.

DR. STONE: A lot of the things that we do in MST are actually modeled the way that medical education proceeds. We see a lot of parallels there. So, I almost compare the mock session to an OSCE, one of the simulated clinical exams that we have with the standardized patients as we go for medical training. It's a similar process. It's kind of a simulation of the real thing, in a way that's very constructive and very feedback-driven. Other elements of our training and just the way that we do our tutoring are similarly modeled. For instance, after each tutoring session, a tutor completes the equivalent of a SOAP note. They do a subjective-objective assessment and plan for the student to give an outline of where things are going. 

Originally, that really was the model that the company was following. It was founded, in part, by a physician, actually, originally back in 2007, and we've really maintained that rigor. What we find is that the tutors really appreciate—even if it's not so explicit in the way that they're training—they really appreciate that the parallels between what they're expected to do in their regular jobs, in their medical training, and what they're asked to do on the tutoring side. It's something that's familiar with them, and very intuitive. 

Then in terms of the second part of your question, to be honest, I am not familiar with any institution that does that, and that really explains the role that our company has. In institutional work that we do do, we really find that that that institutions have individuals or faculty members that either excel in the content, or excel in the process. But it's very rare for them to have individuals that have both. So, that's really the element that we bring to our institutional work. But to answer your question, I'm actually not familiar with any institutions that take that approach and that level of rigor. 

DR. DESAI: That's fantastic. Hopefully, as people become more and more familiar with MST and MST's process, hopefully that will start to seed that idea among institutions as well. I'm curious, you know, there have been a lot of changes. It feels in medicine sometimes like decades go by and nothing changes, and then all of a sudden, a lot of things change. I think we're in the latter right now. A lot of things are changing right now. So, you know, USMLE Step 1. It's been a pillar for a very long time, and now that's going to go to pass/no pass. Step 2, another another pillar, clinical skills, is going to be eliminated in the future. What's your take on these changes? I'm curious to get your thoughts.

DR. STONE: Sure. I think that these changes were really a long time coming. I even remember when I was a first-year medical student—however many years ago that was—and there was talk at that point of creating one single high-stakes exam, where either you passed or you failed, and that was it, but either you were eligible or not eligible for licensure. There was a lot of hype about that. Obviously, that didn't happen, but I think that the driving force behind, certainly the change to pass/fail for Step 1, was the fact that there's just been this unintentional overemphasis by residency program on the USMLE performance as a single metric for suitability for residency. It really has nothing to do with the intended purpose of the exam, which was eligibility for medical licensure. So, this was causing medical students significant distress, myself included. 

I remember my Step 1 prep days way too well, and it was really compromising their well-being, which is understandable. Having one single exam score dictate all of your options in practice of medicine forever is pretty daunting. When you really think about it, it doesn't make much sense. I mean, is it really possible that the same handful of students that score above a 240 or 250 on Step 1 are going to be the best at every specialty? It doesn't really make sense. 

What really needs attention, I think what's going to be the focus now, is the bigger picture of the residency selection process as it goes on in this country. I mean, how do we -- meaning the students, the faculty, the residency programs -- holistically consider student personal strengths, their competencies or clinical abilities,  to really match them with the specialty or specialties that they're best suited for in the sense that they're most likely to thrive in the long term for their entire careers. But most importantly, the ones where they're most likely to deliver the highest quality healthcare for patients and communities, which is the bottom-line most important. 

This transition from medical school to residency is really getting a lot of well-deserved attention from the medical education community. But I do think that, bottom line, medical school is very competitive, and there's always going to be a push to stratify students one way or the other to designate some of them as more elite than others. So, whether this is going to be another overemphasis on Step 2 CK, or whether it's going to be students pushing harder to excel in research productivity or some other metric out there, I think time will tell. At MST, we're pretty open with students at all stages, especially the ones that come for residency advising. We say, “You know, we don't know. Nobody knows what's going to be, but let's take a step back and figure out where you want to be. Let's figure out how we can best guide you to get there.”

DR. DESAI: What is your sense on the overall morale of students? Do they feel mostly like they're taking it all in stride? Do they feel anxious, or nervous about these changes? Especially in the context of the last year and a half of COVID, a lot of feelings have shifted, especially as things have moved online. What is your take on how people are feeling?

DR. STONE: From what I've seen, I think there's always going to be anxiety about any change. Some of these changes were forced by the COVID pandemic, and certainly, there were a lot of students that were impacted significantly in that way. But I think with all of that anxiety that surrounds, “Well, what do I do now? Do I take Step 1 now, or do I wait until it goes pass/fail? How's it going to impact my chances? How are residency programs going to look at me if I'm a re-applicant?” Things like that. I think it's overall a sense of relief, because just the nature of Step 1 and the type of content that was tested, the way it was tested, it was extremely stressful and required a huge amount of a certain kind of studying. They always said, “For Step 1, it's two months, two weeks, a number two pencil.” Step 1, you spend two months studying for, Step 2, two weeks, and Step 3, you walk in. Essentially, meaning that a lot of the information in Step 2 CK and Step 3 is a little more practical; you can draw upon your clinical experience to answer those questions. So, overall I feel, bottom line, that students are relieved. Even though there's a lot of anxiety now with the change, there is a sense of relief that, okay, that's one less thing I have to dedicate two, three, four months of my life to overcoming. I can demonstrate I'm competent. I got what I need to out of the basic sciences and I can move forward. 

DR. DESAI: With that last sentence of moving forward, you know, right now we're in a very awkward time because the US is trying to move forward on the COVID front. Globally, of course, we're seeing some countries devastated by COVID. I'm just curious, you know, you're a clinician. You deal with students, and so you know kind of what the pipeline is looking like for us. What are some things that you feel we can all do to strengthen our healthcare capacity—especially from a personnel standpoint—like training people up to join the clinical workforce, and things that we should do almost immediately to start implementing those changes?

DR. STONE: The COVID-19 crisis really identified some pretty big problems with the delivery of healthcare in the country. Sadly, I don't think that when we take a step back, we were very prepared for the pandemic, and really as a result there was a pretty significant loss of life. That said, I think there were elements that were rather impressive in terms of how the health care providers in the system rapidly came together to address some of the issues as they emerged. For instance, dealing with some of the PPE equipment shortages early on, or, what I saw firsthand was a lot of innovation, in terms of collaborating more informally to very rapidly share clinical information on how best to manage COVID-19 patients to really optimize the outcome—in the moment, almost. That was really something that was impressive.

Also just looking at the vaccine development, which was an incredibly accelerated process, who would have thought that pharmaceutical companies could collaborate to produce the vaccine that was actually available to people in the time frame that it happened? All of this would have been unbelievable prior to the pandemic. So I think, most importantly, we have to take sight of what we accomplished and try to apply the good from that going forward, but also to be very mindful of the areas that do need addressing and need attention. 

Personally, I certainly have watched the tremendous growth, being in dermatology, of the telehealth delivery of care by telemedicine. While it has its limitations, we really did see a nice, really impressive number of patients benefiting from that, and it just expanding the access of patients to physicians, especially dermatologists, who are sometimes in shorter supply in some areas of the country. 

DR. DESAI: That makes sense. I think one other thing that, on our end, especially our listeners really would love to specifically hear from you is around knowledge gaps. You're educated on so many different topics. You're obviously such a skilled educator, and do it professionally, so that obviously takes it to kind of another level. Is there something that you feel our audience—maybe even me, specifically—could benefit from learning, about a topic that you maybe often hear folks get misinformed around and could kind of take a moment now to just teach us something?

DR. STONE: It's a good question. I would take like a broader answer to that and say that it's really more about understanding how differently different people learn, and recognizing that every person comes with a different skillset, essentially, that they've developed over time throughout their trajectory, and that really influences how they learn. What we really see in the tutoring room, or at least in MST, is that students are sometimes looking to us for the right way, for the only way, for the correct way, to master something or to learn something. We really try to guide them to figure out what their individual and unique way of learning is, and to understand— this is a lesson that I have to remind myself very frequently—it is that you can't know everything, especially in medicine. No matter how much of an overachiever you are, even if you spend every hour of your waking moments studying, studying, studying, you're never going to know everything. Yet, you can become competent to treat patients, and to be an excellent doctor and to deliver excellent care in spite of this reality, which for some is pretty frightening. So, that is what I would really emphasize.

DR. DESAI: That makes a ton of sense, and I think that also speaks to the empathy that you probably bring to your teaching sessions in terms of thinking about how people like to learn, what motivates them, and so forth. I guess the final question I have for you is around advice. We have a lot of folks that are starting out their healthcare career. It is kind of an awkward time to be to be looking for a job, or even to be going through clinical training, and here you are; you're a full practicing physician. You have this education company that you work with and for. You obviously are a mentor to many, many people. What advice would you give someone that may be interested in many of the same kinds of things, like research and teaching and clinical work, as you've been interested in in your life? 

DR. STONE: That's a good question as well. I think the first thing I would remind students is that it's a marathon, not a sprint. You're in it for the long haul, and it's not like you set off seeing the light at the end of the tunnel, or even where you're heading, when you start. So spend time now, in two aspects, really: first of all, figuring out what wellness looks like for you. Look at the moments where you're really under stress and note what helps you, because without that self-care component, particularly, if you're taking on multiple roles, you're setting yourself up for burnout. 

Try to give yourself the same care and kindness that you would want to give to your patients. Take note of that, because it's something that will help you, no matter what comes along. It'll help you along the way. By the same token, on the other side of things, really know what excites you. From the day that you start medical school, you've got family members or everybody pretty much who hears you're going to medical school saying, “What kind of doctor are you going to be?” You say, “I don't know yet,” but as you're going along in your trajectory, whether you're in lectures, or rotations, or different patient encounters, note what excites you. You're not expected to be excited by everything, and there will be some things that will excite you more. So mindfully take note of that, and let that knowledge guide you at the moments when you actually have to make those critical decisions that you're facing as a third-year, fourth-year medical student, of what to do with your career, and even going forward. 

Finally, I would say, try to find the magic and the one-to-one connection. There's really nothing—and I've certainly seen this for myself—there's nothing like the dedicated focus of somebody. It could be a tutor but it could also be a colleague or really importantly any sort of mentor. Find people that are like you, or that you like or you admire or respect, and get their input on what worked for them. Spend a lot of time picking their brains. Usually, they're pretty open to it, and get that perspective that's going to be so important for you to go ahead and reach your own goals.

DR. DESAI: That's fantastic. It's very inspirational and very authentic. I appreciate that and I appreciate you joining us today. Dr. Stone, thank you.

DR. STONE: Thank you so much for having me. 

DR. DESAI: I'm Rishi Desai. Thank you for checking out today's show. Remember to do your part to flatten the curve and raise the line. We're all in this together.


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