Brennan M R Spiegel

Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California, United States

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Publications (185)1255.82 Total impact

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    ABSTRACT: Although African Americans have the highest incidence and mortality from colorectal cancer (CRC), they are less likely than other racial groups to undergo CRC screening. Previous research has identified barriers to CRC screening among African Americans. However we lack a systematic review that synthesizes contributing factors and informs interventions to address persistent disparities. We conducted a systematic review to evaluate barriers to colonoscopic CRC screening in African Americans. We developed a conceptual model to summarize the patient-, provider-, and system-level barriers and suggest strategies to address these barriers. Nineteen studies met inclusion criteria. Patient barriers to colonoscopy included fear, poor knowledge of CRC risk, and low perceived benefit of colonoscopy. Provider-level factors included failure to recommend screening and knowledge deficits about guidelines and barriers to screening. System barriers included financial obstacles, lack of insurance and access to care, and intermittent primary care visits. There are modifiable barriers to colonoscopic CRC screening among African Americans. Future interventions should confront patient fear, patient and physician knowledge about barriers, and access to healthcare services. As the Affordable Care Act aims to improve uptake of preventive services, focused interventions to increase CRC screening in African Americans are essential and timely. Copyright © 2014. Published by Elsevier Inc.
    Preventive medicine. 12/2014;
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    ABSTRACT: Objectives:Healthcare delivery now mandates shorter visits with higher documentation requirements, undermining the patient-provider interaction. To improve clinic visit efficiency, we developed a patient-provider portal that systematically collects patient symptoms using a computer algorithm called Automated Evaluation of Gastrointestinal Symptoms (AEGIS). AEGIS also automatically "translates" the patient report into a full narrative history of present illness (HPI). We aimed to compare the quality of computer-generated vs. physician-documented HPIs.Methods:We performed a cross-sectional study with a paired sample design among individuals visiting outpatient adult gastrointestinal (GI) clinics for evaluation of active GI symptoms. Participants first underwent usual care and then subsequently completed AEGIS. Each individual thereby had both a physician-documented and a computer-generated HPI. Forty-eight blinded physicians assessed HPI quality across six domains using 5-point scales: (i) overall impression, (ii) thoroughness, (iii) usefulness, (iv) organization, (v) succinctness, and (vi) comprehensibility. We compared HPI scores within patient using a repeated measures model.Results:Seventy-five patients had both computer-generated and physician-documented HPIs. The mean overall impression score for computer-generated HPIs was higher than physician HPIs (3.68 vs. 2.80; P<0.001), even after adjusting for physician and visit type, location, mode of transcription, and demographics. Computer-generated HPIs were also judged more complete (3.70 vs. 2.73; P<0.001), more useful (3.82 vs. 3.04; P<0.001), better organized (3.66 vs. 2.80; P<0.001), more succinct (3.55 vs. 3.17; P<0.001), and more comprehensible (3.66 vs. 2.97; P<0.001).Conclusions:Computer-generated HPIs were of higher overall quality, better organized, and more succinct, comprehensible, complete, and useful compared with HPIs written by physicians during usual care in GI clinics.Am J Gastroenterol advance online publication, 2 December 2014; doi:10.1038/ajg.2014.356.
    The American journal of gastroenterology. 12/2014;
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    ABSTRACT: OBJECTIVES:The National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS(®)) is a standardized set of patient-reported outcomes (PROs) that cover physical, mental, and social health. The aim of this study was to develop the NIH PROMIS gastrointestinal (GI) symptom measures.METHODS:We first conducted a systematic literature review to develop a broad conceptual model of GI symptoms. We complemented the review with 12 focus groups including 102 GI patients. We developed PROMIS items based on the literature and input from the focus groups followed by cognitive debriefing in 28 patients. We administered the items to diverse GI patients (irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), systemic sclerosis (SSc), and other common GI disorders) and a census-based US general population (GP) control sample. We created scales based on confirmatory factor analyses and item response theory modeling, and evaluated the scales for reliability and validity.RESULTS:A total of 102 items were developed and administered to 865 patients with GI conditions and 1,177 GP participants. Factor analyses provided support for eight scales: gastroesophageal reflux (13 items), disrupted swallowing (7 items), diarrhea (5 items), bowel incontinence/soilage (4 items), nausea and vomiting (4 items), constipation (9 items), belly pain (6 items), and gas/bloat/flatulence (12 items). The scales correlated significantly with both generic and disease-targeted legacy instruments, and demonstrate evidence of reliability.CONCLUSIONS:Using the NIH PROMIS framework, we developed eight GI symptom scales that can now be used for clinical care and research across the full range of GI disorders.Am J Gastroenterol advance online publication, 9 September 2014; doi:10.1038/ajg.2014.237.
    The American journal of gastroenterology. 09/2014;
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    ABSTRACT: Postoperative ileus (POI) can worsen outcomes, increase cost, and prolong hospitalization. An objective marker could help identify POI patients who should not be prematurely fed. We developed a disposable, non-invasive acoustic gastro-intestinal surveillance (AGIS) biosensor. We tested whether AGIS can distinguish healthy controls from patients recovering from abdominal surgery.
    Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract. 08/2014;
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    The American journal of gastroenterology. 08/2014; 109 Suppl 1:S2-S26.
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    ABSTRACT: OBJECTIVES:Irritable bowel syndrome (IBS) and chronic idiopathic constipation (CIC) are functional bowel disorders. Evidence suggests that disturbance in the gastrointestinal microbiota may be implicated in both conditions. We performed a systematic review and meta-analysis to examine the efficacy of prebiotics, probiotics, and synbiotics in IBS and CIC.METHODS:MEDLINE, EMBASE, and the Cochrane Controlled Trials Register were searched (up to December 2013). Randomized controlled trials (RCTs) recruiting adults with IBS or CIC, which compared prebiotics, probiotics, or synbiotics with placebo or no therapy, were eligible. Dichotomous symptom data were pooled to obtain a relative risk (RR) of remaining symptomatic after therapy, with a 95% confidence interval (CI). Continuous data were pooled using a standardized or weighted mean difference with a 95% CI.RESULTS:The search strategy identified 3,216 citations. Forty-three RCTs were eligible for inclusion. The RR of IBS symptoms persisting with probiotics vs. placebo was 0.79 (95% CI 0.70-0.89). Probiotics had beneficial effects on global IBS, abdominal pain, bloating, and flatulence scores. Data for prebiotics and synbiotics in IBS were sparse. Probiotics appeared to have beneficial effects in CIC (mean increase in number of stools per week=1.49; 95% CI=1.02-1.96), but there were only two RCTs. Synbiotics also appeared beneficial (RR of failure to respond to therapy=0.78; 95% CI 0.67-0.92). Again, trials for prebiotics were few in number, and no definite conclusions could be drawn.CONCLUSIONS:Probiotics are effective treatments for IBS, although which individual species and strains are the most beneficial remains unclear. Further evidence is required before the role of prebiotics or synbiotics in IBS is known. The efficacy of all three therapies in CIC is also uncertain.Am J Gastroenterol advance online publication, 29 July 2014; doi:10.1038/ajg.2014.202.
    The American journal of gastroenterology. 07/2014;
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    ABSTRACT: OBJECTIVES:Fiber has been used for many years to treat irritable bowel syndrome (IBS). This approach had fallen out of favor until a recent resurgence, which was based on new randomized controlled trial (RCT) data that suggested it might be effective. We have previously conducted a systematic review of fiber in IBS, but new RCT data for fiber therapy necessitate a new analysis; thus, we have conducted a systematic review of this intervention.METHODS:MEDLINE, EMBASE, and the Cochrane Controlled Trials Register were searched up to December 2013. Trials recruiting adults with IBS, which compared fiber supplements with placebo, control therapy, or "usual management", were eligible. Dichotomous symptom data were pooled to obtain a relative risk (RR) of remaining symptomatic after therapy as well as number needed to treat (NNT) with a 95% confidence interval (CI).RESULTS:We identified 14 RCTs involving 906 patients that had evaluated fiber in IBS. There was a significant benefit of fiber in IBS (RR=0.86; 95% CI 0.80-0.94 with an NNT=10; 95% CI=6-33). There was no significant heterogeneity between results (I(2)=0%, Cochran Q=13.85 (d.f.=14), P=0.46). The benefit was only seen in RCTs on soluble fiber (RR=0.83; 95% CI 0.73-0.94 with an NNT=7; 95% CI 4-25) with no effect seen with bran (RR=0.90; 95% CI 0.79-1.03).CONCLUSIONS:Soluble fiber is effective in treating IBS. Bran did not appear to be of benefit, although we did not uncover any evidence of harm from this intervention, as others have speculated from uncontrolled data.Am J Gastroenterol advance online publication, 29 July 2014; doi:10.1038/ajg.2014.195.
    The American journal of gastroenterology. 07/2014;
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    ABSTRACT: Colonic diverticular disease is typically conceived as acute diverticulitis attacks surrounded by periods of clinical silence. However, evolving data indicate that many patients have persistent symptoms and diminished health-related quality of life (HRQOL) long after acute attacks. We developed a disease-targeted HRQOL measure for symptomatic uncomplicated diverticular disease (SUDD)-the diverticulitis quality of life (DV-QOL) instrument.
    Gastroenterology 07/2014; · 12.82 Impact Factor
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    ABSTRACT: OBJECTIVES:Irritable bowel syndrome (IBS) is a chronic functional gastrointestinal disorder. Evidence relating to the treatment of this condition with antidepressants and psychological therapies continues to accumulate.METHODS:We performed an updated systematic review and meta-analysis of randomized controlled trials (RCTs). MEDLINE, EMBASE, and the Cochrane Controlled Trials Register were searched (up to December 2013). Trials recruiting adults with IBS, which compared antidepressants with placebo, or psychological therapies with control therapy or "usual management," were eligible. Dichotomous symptom data were pooled to obtain a relative risk (RR) of remaining symptomatic after therapy, with a 95% confidence interval (CI).RESULTS:The search strategy identified 3,788 citations. Forty-eight RCTs were eligible for inclusion: thirty-one compared psychological therapies with control therapy or "usual management," sixteen compared antidepressants with placebo, and one compared both psychological therapy and antidepressants with placebo. Ten of the trials of psychological therapies, and four of the RCTs of antidepressants, had been published since our previous meta-analysis. The RR of IBS symptom not improving with antidepressants vs. placebo was 0.67 (95% CI=0.58-0.77), with similar treatment effects for both tricyclic antidepressants and selective serotonin reuptake inhibitors. The RR of symptoms not improving with psychological therapies was 0.68 (95% CI=0.61-0.76). Cognitive behavioral therapy, hypnotherapy, multicomponent psychological therapy, and dynamic psychotherapy were all beneficial.CONCLUSIONS:Antidepressants and some psychological therapies are effective treatments for IBS. Despite the considerable number of studies published in the intervening 5 years since we last examined this issue, the overall summary estimates of treatment effect have remained remarkably stable.Am J Gastroenterol advance online publication, 17 June 2014; doi:10.1038/ajg.2014.148.
    The American journal of gastroenterology. 06/2014;
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    ABSTRACT: Prior estimates suggest that up to 40 % of the US general population (GP) report symptoms of gastroesophageal reflux disease (GERD). However, symptoms in the GP versus patients seeking care for gastrointestinal (GI) complaints have not been compared. We estimated the prevalence and severity of GERD symptoms in the GP versus GI patients, and identified predictors of GERD severity. We hypothesized that similar to functional GI disorders, psychosocial factors would predict symptom severity in GERD as much, or perhaps more, than care-seeking behavior alone. We compared the prevalence of heartburn and regurgitation between a sample from the US GP and patients seeking GI specialty care. We compared GERD severity between groups using the NIH PROMIS(®) GERD scale. We then performed multivariable regression to identify predictors of GERD severity. There was no difference in the prevalence of heartburn between the GP and patient groups (59 vs. 59 %), but regurgitation was more common in patients versus GP (46 vs. 39 %; p = 0.004). In multivariable regression, having high visceral anxiety (p < 0.001) and being divorced or separated (p = 0.006) were associated with higher GERD severity. More than half of a GP sample reports heartburn-higher than previous series and no different from GI patients. Although regurgitation was more prevalent in patients versus the GP, there was no difference in GERD severity between groups after adjusting for other factors; care seeking in GERD appears related to factors beyond symptoms, including visceral anxiety.
    Digestive Diseases and Sciences 05/2014; · 2.26 Impact Factor
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    ABSTRACT: Objective: Gastrointestinal (GI) involvement is common in patients with systemic sclerosis (SSc). The Patient-Reported Outcomes Measurement Information System (PROMIS®) GI Symptom item bank captures upper and lower GI symptoms (reflux, disrupted swallowing, nausea/vomiting, belly pain, gas /bloating /flatulence, diarrhea, constipation, and fecal incontinence). The objective of this study was to evaluate the construct validity of the PROMIS-GI bank in SSc. Methods: 167 patients with SSc were administered the PROMIS GI bank and the UCLA Scleroderma Clinical Trials Consortium Gastrointestinal Scale (GIT 2.0) instrument. GIT 2.0 is a multi-item instrument that measures SSc-associated GI symptoms. Product-moment correlations and a multitrait-multimethod analysis of the PROMIS GI scales with the GIT 2.0 symptom scales were used to evaluate convergent and discriminant validity. Results: Patients with SSc GI involvement had PROMIS GI scale scores 0.2-0.7 SD worse than US population. Correlations among scales measuring the same domains for the PROMIS GI and GIT 2.0 measures were large, ranging from 0.61 to 0.87 (average r = 0.77). The average correlation between different symptom scales was 0.22, supporting discriminant validity. Conclusion: This study provides support for the construct validity of the PROMIS GI scales in SSc. Future research is needed to assess the responsiveness to change of these scales in patients with SSc. © 2014 American College of Rheumatology.
    Arthritis care & research. 04/2014;
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    ABSTRACT: Background African Americans have the highest incidence and mortality from colorectal cancer (CRC). Despite guidelines to initiate screening with colonoscopy at age 45 in African Americans, the CRC incidence remains high in this group. Objective To examine the rates and predictors of CRC screening uptake as well as time to screening in a population of African Americans and non–African Americans in a health care system that minimizes variations in insurance and access. Design Retrospective cohort study. Setting Greater Los Angeles Veterans Affairs (VA) Healthcare System. Patients Random sample (N = 357) of patients eligible for initial CRC screening. Main Outcome Measurements Uptake of any screening method; uptake of colonoscopy, in particular; predictors of screening; and time to screening in African Americans and non–African Americans. Results The overall screening rate by any method was 50%. Adjusted rates for any screening were lower among African Americans than non–African Americans (42% vs 58%; odds ratio [OR] 0.49; 95% confidence interval [CI], 0.31–0.77). Colonoscopic screening was also lower in African Americans (11% vs 23%; adjusted OR 0.43; 95% CI, 0.24–0.77). In addition to race, homelessness, lower service connectedness, taking more prescription drugs, and not seeing a primary care provider within 2 years of screening eligibility predicted lower uptake of screening. Time to screening colonoscopy was longer in African Americans (adjusted hazard ratio 0.43; 95% CI, 0.25–0.75). Limitations The sample may not be generalizable. Conclusions We found marked disparities in CRC screening despite similar access to care across races. Despite current guidelines aimed at increasing CRC screening in African Americans, participation in screening remained low, and use of colonoscopy was infrequent.
    Gastrointestinal endoscopy 01/2014; · 6.71 Impact Factor
  • Article: Reply.
    Brennan M R Spiegel
    Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association 08/2013; · 5.64 Impact Factor
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    ABSTRACT: Red blood cell transfusion was previously the principle therapy for anemia in CKD but became less prevalent after the introduction of erythropoiesis-stimulating agents. This study used adaptive choice-based conjoint analysis to identify preferences and predictors of transfusion decision-making in CKD. A computerized adaptive choice-based conjoint survey was administered between June and August of 2012 to nephrologists, internists, and hospitalists listed in the American Medical Association Masterfile. The survey quantified the relative importance of 10 patient attributes, including hemoglobin levels, age, occult blood in stool, severity of illness, eligibility for transplant, iron indices, erythropoiesis-stimulating agents, cardiovascular disease, and functional status. Triggers of transfusions in common dialysis scenarios were studied, and based on adaptive choice-based conjoint-derived preferences, relative importance by performing multivariable regression to identify predictors of transfusion preferences was assessed. A total of 350 providers completed the survey (n=305 nephrologists; mean age=46 years; 21% women). Of 10 attributes assessed, absolute hemoglobin level was the most important driver of transfusions, accounting for 29% of decision-making, followed by functional status (16%) and cardiovascular comorbidities (12%); 92% of providers transfused when hemoglobin was 7.5 g/dl, independent of other factors. In multivariable regression, Veterans Administration providers were more likely to transfuse at 8.0 g/dl (odds ratio, 5.9; 95% confidence interval, 1.9 to 18.4). Although transplant eligibility explained only 5% of decision-making, nephrologists were five times more likely to value it as important compared with non-nephrologists (odds ratio, 5.2; 95% confidence interval, 2.4 to11.1). Adaptive choice-based conjoint analysis was useful in predicting influences on transfusion decisions. Hemoglobin level, functional status, and cardiovascular comorbidities most strongly influenced transfusion decision-making, but preference variations were observed among subgroups.
    Clinical Journal of the American Society of Nephrology 08/2013; · 5.07 Impact Factor
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    ABSTRACT: & Aims: Colonic diverticulosis is the most common finding during routine colonoscopy, and patients often question the significance of these lesions. Guidelines state that these patients have a 10%-25% lifetime risk of developing acute diverticulitis. However, this value was determined based on limited data, collected before population-based colonoscopy, so the true number of cases of diverticulosis was not known. We measured the long-term risk of acute diverticulitis among patients with confirmed diverticulosis, discovered incidentally on colonoscopy. We performed a retrospective study using administrative and clinical data from the Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS), collecting data on 3992 patients who underwent colonoscopies from January 1996 through January 2011. We identified patients diagnosed with diverticulosis, determined incidence rates per 1000 patient-years, and analyzed a sub-group of patients with rigorously defined events confirmed by imaging or surgery. We used a Cox proportional hazards model to identify factors associated with development of diverticulitis. We identified 2222 patients with baseline diverticulosis. Over an 11-year follow-up, 95 patients developed diverticulitis (4.3%, 6/1000 patient-years); of these, 23 met the rigorous definition of diverticulitis (1%; 1.5/1000 patient-years). The median time-to-event was 7.1 years. Each additional decade of age at time of diagnosis reduced the risk for diverticulitis by 24% (hazard ratio, 0.76; 95% confidence interval, 0.6-0.9). Based on a study of the VAGLAHS, only about 4% of patients with diverticulosis develop acute diverticulitis, contradicting the common belief that diverticulosis has a high rate of progression. We also found that younger patients have higher risk of diverticulitis, with risk increasing per year of life. These results can help inform patients with diverticulosis about their risk of developing acute diverticulitis.
    Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association 07/2013; · 5.64 Impact Factor
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    ABSTRACT: To evaluate the cost-effectiveness of competing gastroprotective strategies, including single-tablet formulations, in the prevention of gastrointestinal (GI) complications in patients with chronic arthritis taking nonsteroidal anti-inflammatory drugs (NSAIDs). We performed a cost-utility analysis to compare eight gastroprotective strategies including NSAIDs, cyclooxygenase-2 inhibitors, proton pump inhibitors (PPIs), histamine-2 receptor antagonists, misoprostol, and single-tablet formulations. We derived estimates for outcomes and costs from medical literature. The primary outcome was incremental cost per quality-adjusted life-year gained. We performed sensitivity analyses to assess the effect of GI complications, compliance rates, and drug costs. For average-risk patients, NSAID + PPI cotherapy was most cost-effective. The NSAID/PPI single-tablet formulation became cost-effective only when its price decreased from €0.78 to €0.56 per tablet, or when PPI compliance fell below 51% in the NSAID + PPI strategy. All other strategies were more costly and less effective. The model was highly sensitive to the GI complication risk, costs of PPI and NSAID/PPI single-tablet formulation, and compliance to PPI. In patients with a threefold higher risk of GI complications, both NSAID + PPI cotherapy and single-tablet formulation were cost-effective. NSAID + PPI cotherapy is the most cost-effective strategy in all patients with chronic arthritis irrespective of their risk for GI complications. For patients with increased GI risk, the NSAID/PPI single-tablet formulation is also cost-effective.
    Value in Health 07/2013; 16(5):769-77. · 2.19 Impact Factor
  • Digestive Disease Week 2013; 05/2013
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    ABSTRACT: Background: Irritable bowel syndrome (IBS) is a chronic functional gastrointestinal disorder characterized by abdominal pain or discomfort associated with altered bowel habits. IBS is sub-typed based on predominant bowel habits: diarrhea-predominant (IBS-D), constipation- predominant (IBS-C), or mixed (IBS-M). There is currently no patient-reported outcome (PRO) measure that is accepted as well-defined and reliable by the FDA for use in determining therapeutic benefit of novel agents in IBS. Therefore, the FDA recommends using interim composite primary endpoints based on abdominal pain ratings and stool consistency (IBS- D) or stool frequency (IBS-C) in clinical treatment trials. Aim: To conduct qualitative research with IBS participants to elicit their symptom experience in accordance with the FDA's Guidance for development of a PRO instrument. Method: Prior to conducting interviews, we performed a targeted literature search, developed a conceptual framework, and conferred with an expert panel. Face-to-face interviews were conducted in a representative adult sample in three US geographic locations. Participants had a physician confirmed diagnosis of IBS- D (n=17), IBS-C (n=14) or IBS-M (n=18) per Rome III. Additional screening criteria ensured interview participants were similar to IBS clinical trial participants. Each interview was conducted according to a semi-structured interview guide including spontaneous concept elicitation, probed concept elicitation, and identification of symptoms most bothersome and important to measure. Analysis of the qualitative data, using ATLAS.ti software, identified dominant trends within and across interviews to evaluate participant's descriptions of IBS symptoms. Results: Concept elicitation (mean age 46.7, 84% F, 63% white) revealed a range of symptom experiences attributed to IBS. Participants reported urgency (IBS-D), bloating (IBS-C), and cramping and abdominal pain (IBS-M) as most bothersome symptoms. While almost all IBS participants reported abnormal stool consistency and frequency and abdominal pain, more IBS-D experienced urgency, IBS-C reported more bloating symptoms, and IBS- M shared symptoms with both. The most frequently reported symptoms were also the most bothersome and among the most important symptoms to treat. Conclusion: IBS patients report a range of gastrointestinal symptoms that includes but is not limited to abdominal pain and abnormal stool consistency and frequency. Findings from this qualitative research suggest that symptoms common across subtypes or specific to each subtype should be considered to comprehensively capture patients' experience on an IBS treatment. Further work will include development of an item set, cognitive debriefing, and evaluation of the instrument's psychometric properties. This qualitative work stands to support the foundation for future PRO development in IBS.
    Gastroenterology 05/2013; 144(5):S-546. · 12.82 Impact Factor
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    Brennan M R Spiegel
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    ABSTRACT: Patient-generated reports, also known as Patient-Reported Outcomes (PROs), capture the patients' illness experience in a structured format and may help bridge the gap between patients and providers. PROs measure any aspect of patient-reported health (e.g., physical, emotional or social symptoms) and can help to direct care and improve clinical outcomes. When clinicians systematically collect patient-reported data in the right place at the right time, PRO measurement can effectively aid in detection and management of conditions, improve satisfaction with care and enhance the patient-provider relationship. This review article summarizes the latest approaches to PRO measuring for clinical trials and clinical practice, with a focus on use of PROs in gastroenterology.
    Journal of neurogastroenterology and motility 04/2013; 19(2):137-48.

Publication Stats

3k Citations
1,255.82 Total Impact Points


  • 2014
    • Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center
      Torrance, California, United States
  • 2003–2014
    • VA Greater Los Angeles Healthcare System
      Los Angeles, California, United States
  • 2003–2013
    • University of California, Los Angeles
      • • Division of Digestive Diseases
      • • Department of Medicine
      Los Angeles, CA, United States
  • 2012
    • University of Washington Seattle
      • Division of Gastroenterology
      Seattle, WA, United States
  • 2011–2012
    • Harvard Medical School
      Boston, Massachusetts, United States
    • Emory University
      • Division of Digestive Diseases
      Atlanta, GA, United States
  • 2009–2011
    • Stanford Medicine
      • Department of Medicine
      Stanford, California, United States
  • 2008–2011
    • University of Southern California
      • Division of Gastrointestinal and Liver Diseases
      Los Angeles, California, United States
    • University of California, San Francisco
      • Division of Hospital Medicine
      San Francisco, CA, United States
    • CSU Mentor
      Long Beach, California, United States
  • 2010
    • Concordia University–Ann Arbor
      Ann Arbor, Michigan, United States
    • Saint Louis University
      Saint Louis, Michigan, United States
  • 2008–2009
    • McMaster University
      • Division of Pediatric Gastroenterology
      Hamilton, Ontario, Canada
  • 2007
    • Technion - Israel Institute of Technology
      • Rambam Medical Center
      Haifa, Haifa District, Israel
  • 2004
    • University of Manitoba
      Winnipeg, Manitoba, Canada
  • 2002
    • Cedars-Sinai Medical Center
      • Cedars Sinai Medical Center
      Los Angeles, CA, United States