Robert M Arnold

Icahn School of Medicine at Mount Sinai, Borough of Manhattan, New York, United States

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Publications (444)2228.55 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Purpose . To assess use, screening, and disclosure of perinatal marijuana and other illicit drugs during first obstetric visits. Design . Observational study that qualitatively assesses provider screening and patient disclosure of substance use. Setting . Study sites were five urban outpatient prenatal clinics and practices located in Pittsburgh, Pennsylvania. Participants . Pregnant patients and obstetric providers were recruited as participants. Methods . We audio recorded patient-provider conversations during first obstetric visits and obtained patient urine samples for drug analyses. Audio recordings were reviewed for provider screening and patient disclosure of illicit drug use. Urine analyses were compared with audio recordings to determine disclosure. Results . Four hundred and twenty-two pregnant patients provided complete audio recordings and urine samples for analyses. Providers asked about illicit drug use in 81% of the visits. One hundred twenty-three patients (29%) disclosed any current or past illicit drug use; 48 patients (11%) disclosed current use of marijuana while pregnant. One hundred and forty-five samples (34%) tested positive for one or more substances; marijuana was most commonly detected (N = 114, 27%). Of patients who tested positive for any substance, 66 (46%) did not disclose any use; only 36% of patients who tested positive for marijuana disclosed current use. Conclusion . Although marijuana is illegal in Pennsylvania, a high proportion of pregnant patients used marijuana, with many not disclosing use to their obstetric care providers.
    American journal of health promotion: AJHP 11/2015; DOI:10.4278/ajhp.141215-QUAL-625 · 2.37 Impact Factor
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    ABSTRACT: Institutional Review Boards (IRBs) are intended to protect those who participate in research. However, because there is no established measure of IRB quality, it is unclear whether these committees achieve their goal. The IRB Researcher Assessment Tool is a previously validated, internally normed, proxy measure of IRB quality that assesses 45 distinct IRB activities and functions. We administered this instrument to a sample of investigators and IRB members at a large urban VA Medical Center. We describe a systematic approach to analyze and interpret survey responses that can identify the IRB activities and functions most in need of quality improvement. The proposed approach to empirical data analysis and presentation could inform local initiatives to improve the quality of IRB review.
    Journal of Empirical Research on Human Research Ethics 11/2015; DOI:10.1177/1556264615612195 · 1.25 Impact Factor

  • Cancer 10/2015; DOI:10.1002/cncr.29754 · 4.89 Impact Factor

  • American Journal of Respiratory and Critical Care Medicine 10/2015; DOI:10.1164/rccm.201508-1592OE · 13.00 Impact Factor

  • Journal of the American College of Surgeons 10/2015; 221(4):e14. DOI:10.1016/j.jamcollsurg.2015.08.331 · 5.12 Impact Factor
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    ABSTRACT: Purpose: There is a paucity of scalable advance care planning strategies that achieve the diverse goals of patients, families, and clinicians. We convened key stakeholders to gain their perspectives on developing a Web-based advance care planning tool for lung disease. Materials and methods: We conducted semistructured interviews with 50 stakeholders: 21 patients with lung disease, 18 surrogates, and 11 clinicians. Interviews explored stakeholders' desired content and design features of a Web-based advance care planning tool. Participants also rated the tool's acceptability and potential usefulness. We analyzed the interviews with modified grounded theory and validated themes through member checking. Results: Stakeholders highly rated the acceptability (median, 5; interquartile range, 5-5) and potential usefulness (median, 5; interquartile range, 4-5) of a Web-based tool. Interviewees offered several suggestions: (1) use videos of medical scenarios and patient narratives rather than text, (2) include interactive content, and (3) allow the user control over how much they complete in 1 sitting. Participants identified challenges and potential solutions, such as how to manage the emotional difficulty of thinking about death and accommodate low computer literacy users. Conclusions: There is strong stakeholder support for the development of a Web-based advance care planning tool for lung disease.
    Journal of critical care 09/2015; 30(6). DOI:10.1016/j.jcrc.2015.09.001 · 2.00 Impact Factor
  • Yael Schenker · Robert Arnold ·

    JAMA The Journal of the American Medical Association 09/2015; 314(15):1-2. DOI:10.1001/jama.2015.11217 · 35.29 Impact Factor
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    ABSTRACT: This article aims to discuss the rapidly growing field of palliative medicine and its unique approach to treating depression in older adults.
    Harvard Review of Psychiatry 09/2015; 23(5):343-53. DOI:10.1097/HRP.0000000000000069 · 1.73 Impact Factor
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    ABSTRACT: Participating in a decision to limit life support for a loved one in the ICU is associated with adverse mental health consequences for surrogate decision makers. We sought to describe acutely bereaved surrogates' experiences surrounding this decision. Qualitative analysis of interviews with surrogates approximately 4 weeks after a patient's death in one of six ICUs at four hospitals in Pittsburgh, PA. Adults who participated in decisions about life support in the ICU. Not applicable. We collected participant demographics, previous advance care planning, and decision control preferences. We used qualitative content analysis of transcribed interviews to identify themes in surrogates' experiences. The 23 participants included the spouse (n = 7), child/stepchild (7), sibling (5), parent (3), or other relation (1) of the deceased patient. Their mean age was 55, 61% were women, all were whites, 74% had previous treatment preference discussions with the patient, and 43% of patients had written advance directives. Fifteen of 23 surrogates (65%) preferred an active decision-making role, 8 of 23 (35%) preferred to share responsibility with the physician, and no surrogates preferred a passive role. Surrogates report that key stressors in the ICU are the uncertainty and witnessed or empathic suffering. These factors contributed to surrogates' sense of helplessness in the ICU. Involvement in the decision to limit life support allowed surrogates to regain a sense of agency by making a decision consistent with the patient's wishes and values, counteracting surrogates' helplessness and ending the uncertainty and suffering. In this all-white sample of surrogates with nonpassive decision control preferences from a single US region, participating in decision making allowed surrogates to regain control, counteract feelings of helplessness, and end their empathic suffering. Although previous research highlighted the distress caused by participation in a decision to limit life support, the act of decision making may, counterintuitively, help some surrogates cope with the experience.
    Critical care medicine 08/2015; 43(11). DOI:10.1097/CCM.0000000000001270 · 6.31 Impact Factor
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    ABSTRACT: Although numerous studies have documented that family members in intensive care units struggle with end-of-life decisions for incapacitated patients, there is little information about whether prior advance care planning lessens the burden of decision making. We sought to measure decisional conflict in surrogates of critically ill patients and examine whether prior advance care planning is associated with less decisional conflict. We performed a secondary data analysis of a multicenter, prospective cohort study from five U.S. academic medical centers that included 471 surrogates of 257 patients with acute respiratory distress syndrome. The main outcome was surrogates' burden of decision making as measured by the Decisional Conflict Scale. Surrogates completed a questionnaire item addressing whether they had any prior advance care planning conversations with their loved one. We used multilevel linear regression modeling to measure the association between decisional conflict and advance care planning. Moderate or high levels of decisional conflict (score ≥ 25) were present in 48% of surrogates. After adjusting for potential confounders, surrogates who had engaged in prior advance care planning conversations had significantly lower levels of decisional conflict compared to those who had not (scored a mean of 3.3 points lower (95% CI: -6.4 to -0.2) on the decisional conflict scale; p=0.03). Nearly half of surrogates for critically ill patients have moderate or high levels of decisional conflict. Prior advance care planning was associated with less decisional conflict. These results suggest that the scope of benefit of advance care planning may extend beyond respecting patients' wishes to also ameliorate the burden placed on patients' loved ones who act as surrogates.
    Annals of the American Thoracic Society 08/2015; 12(10). DOI:10.1513/AnnalsATS.201504-253OC
  • Daniel E Hall · Barbara H Hanusa · Michael J Fine · Robert M Arnold ·
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    ABSTRACT: Background: Previous studies of surgeon behavior report that surgeons rarely meet basic standards of informed consent, raising concerns that current practice requires urgent remediation. We wondered if the Veterans Affairs Healthcare System's recent implementation of standardized, procedure-specific consent forms might produce a better practice of informed consent than has been reported previously. Our goal was to determine how the discussions shared between surgeons and patients correspond to the VA's standardized consent forms. Methods: We enrolled a prospective cohort of patients presenting for possible cholecystectomy or inguinal herniorrhaphy and the surgical providers for those patients. Audio recordings captured the clinical encounter(s) culminating in a decision to have surgery. Each patient's informed consent was documented using a standardized, computer-generated form. We abstracted and compared the information documented with the information discussed. Results: Of 75 consecutively enrolled patients, 37 eventually decided to have surgery and signed the standardized consent form. Patients and providers discussed 37% (95% confidence interval, 0.07-0.67) and 33% (95% confidence interval, 0.21-0.43) of the information found on the cholecystectomy and herniorrhaphy consent forms, respectively. However, the patient-provider discussions frequently included relevant details nowhere documented on the standardized forms, culminating in discussions that included a median 27.5 information items for cholecystectomy and 20 items for herniorrhaphy. Fully, 80% of cholecystectomy discussions and 76% of herniorrhaphy discussions mentioned at least one risk, benefit or alternative, indication for, and description of the procedure. Conclusions: The patients and providers observed here collaborated in a detailed process of informed consent that challenges the initial reports suggesting the need to remediate surgeon's practice of informed consent. However, because the discrepancy between the information documented and discussed exposes legal and ethical liability, there is an opportunity to improve the iMed system so that it better reflects what surgeons discuss and more frequently includes all the information patients need.
    Journal of Surgical Research 03/2015; 197(1). DOI:10.1016/j.jss.2015.03.058 · 1.94 Impact Factor
  • Jared Chiarchiaro · Robert M Arnold · Douglas B White ·

    JAMA The Journal of the American Medical Association 03/2015; 313(11):1103-1104. DOI:10.1001/jama.2015.0569 · 35.29 Impact Factor
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    ABSTRACT: Although misperceptions about prognosis by surrogates in ICUs are common and influence treatment decisions, there is no validated, practical way to measure the effectiveness of prognostic communication. Surrogates' subjective ratings of quality of communication have been used in other domains as markers of effectiveness of communication. We sought to determine whether surrogates' subjective ratings of the quality of prognostic communication predict accurate expectation about prognosis by surrogates. We performed a cross-sectional cohort study. Surrogates rated the quality of prognostic communication by survey. Physicians and surrogates gave their percentage estimate of patient survival on ICU day 3 on a 0-100 probability scale. We defined discordance about prognosis as a difference in the physician's and surrogate's estimates of greater than or equal to ±20%. We used multilevel logistic regression modeling to account for clustering under physicians and patients and adjust for confounders. Medical-surgical, trauma, cardiac, and neurologic ICUs of five U.S. academic medical centers located in California, Pennsylvania, Washington, North Carolina, and Massachusetts. Two hundred seventy-five patients with acute respiratory distress syndrome at high risk of death or severe functional impairment, their 546 surrogate decision makers, and their 150 physicians. None. There was no predictive utility of surrogates' ratings of the quality of communication about prognosis to identify inaccurate expectations about prognosis (odds ratio, 1.04 ± 0.07; p = 0.54). Surrogates' subjective ratings of the quality of communication about prognosis were high, as assessed with a variety of questions. Discordant prognostic estimates were present in 63.5% (95% CI, 59.0-67.9) of physician-surrogate pairs. Although most surrogates rate the quality of prognostic communication high, inaccurate expectations about prognosis are common among surrogates. Surrogates' ratings of the quality of prognostic communication do not reliably predict an accurate expectation about prognosis.
    Critical Care Medicine 03/2015; 43(3):542-548. DOI:10.1097/CCM.0000000000000719 · 6.31 Impact Factor
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    ABSTRACT: Patients often struggle to express their emotional concerns to their oncology providers and may therefore experience unmet needs. This paper describes the development and implementation of an online program that teaches patients how to communicate their emotions to their oncology providers. The intervention was developed by a multidisciplinary team consisting of palliative care physicians, psychologists, and an intervention software developer and included input from patients. It incorporated elements of Social Cognitive Theory and validated cognitive behavioral strategies for communication skills training. Strategies to increase intervention adherence were implemented midway through the study. The intervention consists of four interactive, online modules to teach patients strategies for expressing emotional concerns to their providers and asking for support. In addition to skill-building, the intervention was designed to raise patients' expectations that expressing emotional concerns to providers would be helpful, to enhance their self-efficacy for doing so, and to help them overcome barriers to having these conversations. After implementing strategies to improve adherence, usage rates increased from 47 to 64 %. This intervention addresses an unmet educational need for patients with advanced cancer. Strategies to increase adherence led to improvements in usage rates in this population of older patients. We are currently evaluating the intervention in a randomized clinical trial to determine its efficacy in increasing patient expression of emotional concerns and requests for support. If successful, this intervention could serve as a model for future online patient education programs.
    Supportive Care Cancer 02/2015; 23(10). DOI:10.1007/s00520-015-2656-2 · 2.36 Impact Factor
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    ABSTRACT: Rationale: Although medical simulation is increasingly being used in healthcare education, there are few examples of how to rigorously design a simulation to evaluate and study important communication skills of intensive care unit (ICU) clinicians. Objectives: To use existing best practice recommendations to develop a medical simulation to study conflict management in ICUs, then assess the feasibility, acceptability, and realism of the simulation among ICU clinicians. Methods: The setting was a medical ICU of a tertiary care, university hospital. Participants were 36 physicians who treat critically ill patients: intensivists, palliative medicine specialists, and trainees. Using best-practice guidelines and an iterative, multidisciplinary approach, we developed and refined a simulation involving a critically ill patient, in which the patient had a clear advance directive specifying no use of life support, and a surrogate who was unwilling to follow the patient's preferences. ICU clinicians participated in the simulation and completed surveys and semistructured interviews to assess the feasibility, acceptability, and realism of the simulation. Measurements and Main Results: All participants successfully completed the simulation, and all perceived conflict with the surrogate (mean conflict score, 4.2 on a 0-10 scale [SD, 2.5; range, 1-10]). Participants reported high realism of the simulation across a range of criteria, with mean ratings of greater than 8 on a 0 to 10 scale for all domains assessed. During semistructured interviews, participants confirmed a high degree of realism and offered several suggestions for improvements. Conclusions: We used existing best practice recommendations to develop a simulation model to study physician-family conflict in ICUs that is feasible, acceptable, and realistic.
    02/2015; 12(4). DOI:10.1513/AnnalsATS.201411-495OC
  • Lisa Podgurski · Rene Claxton · Carol Greco · Andrea Croom · Robert Arnold ·

    Journal of Pain and Symptom Management 02/2015; 49(2):384-385. DOI:10.1016/j.jpainsymman.2014.11.138 · 2.80 Impact Factor
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    ABSTRACT: Patients with hematologic malignancies are less likely to receive specialist palliative care services than patients with solid tumors. Reasons for this difference are poorly understood. This was a multisite, mixed-methods study to understand and contrast perceptions of palliative care among hematologic and solid tumor oncologists using surveys assessing referral practices and in-depth semistructured interviews exploring views of palliative care. We compared referral patterns using standard statistical methods. We analyzed qualitative interview data using constant comparative methods to explore reasons for observed differences. Among 66 interviewees, 23 oncologists cared exclusively for patients with hematologic malignancies; 43 treated only patients with solid tumors. Seven (30%) of 23 hematologic oncologists reported never referring to palliative care; all solid tumor oncologists had previously referred. In qualitative analyses, most hematologic oncologists viewed palliative care as end-of-life care, whereas most solid tumor oncologists viewed palliative care as a subspecialty that could assist with complex patient cases. Solid tumor oncologists emphasized practical barriers to palliative care referral, such as appointment availability and reimbursement issues. Hematologic oncologists emphasized philosophic concerns about palliative care referrals, including different treatment goals, responsiveness to chemotherapy, and preference for controlling even palliative aspects of patient care. Most hematologic oncologists view palliative care as end-of-life care, whereas solid tumor oncologists more often view palliative care as a subspecialty for comanaging patients with complex cases. Efforts to integrate palliative care into hematologic malignancy practices will require solutions that address unique barriers to palliative care referral experienced by hematologic malignancy specialists. Copyright © 2015 by American Society of Clinical Oncology.
    Journal of Pain and Symptom Management 02/2015; 49(2):393-394. DOI:10.1016/j.jpainsymman.2014.11.157 · 2.80 Impact Factor
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    ABSTRACT: Although shared decision making requires clinicians to discuss the patient's values and preferences, little is known about the extent to which this occurs with surrogates in ICUs. We sought to assess whether and how clinicians talk with surrogates about incapacitated patients' preferences and values. Prospective, cross-sectional study. Five ICUs of two hospitals. Fifty-four physicians and 159 surrogates for 71 patients. We audio-recorded 71 conferences in which clinicians and surrogates discussed life-sustaining treatment decisions for an incapacitated patient near the end of life. Two coders independently coded each instance in which clinicians or surrogates discussed the patient's previously expressed treatment preferences or values. They subcoded for values that are commonly important to patients near the end of life. They also coded treatment recommendations by clinicians that incorporated the patient's preferences or values. In 30% of conferences, there was no discussion about the patient's previously expressed preferences or values. In 37%, clinicians and surrogates discussed both the patient's treatment preferences and values. In the remaining 33%, clinicians and surrogates discussed either the patient's treatment preferences or values, but not both. In more than 88% of conferences, there was no conversation about the patient's values regarding autonomy and independence, emotional well-being and relationships, physical function, cognitive function, or spirituality. On average, 3.8% (SD, 4.3; range, 0-16%) of words spoken pertained to patient preferences or values. In roughly a third of ICU family conferences for patients at high risk of death, neither clinicians nor surrogates discussed patients' preferences or values about end-of-life decision making. In less than 12% of conferences did participants address values of high importance to most patients, such as cognitive and physical function. Interventions are needed to ensure patients' values and preferences are elicited and integrated into end-of-life decisions in ICUs.
    Critical Care Medicine 01/2015; 43(4). DOI:10.1097/CCM.0000000000000772 · 6.31 Impact Factor
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    ABSTRACT: Abstract Background: Specialty palliative care is not accessible for many patients with advanced cancer. There is a need to find alternative palliative care strategies in oncology clinics. Objective: The objective of the study was to assess the feasibility, acceptability, and perceived effectiveness of an oncology nurse-led care management approach to improve primary palliative care. Methods: The study design was a single-arm pilot trial of the Care Management by Oncology Nurses (CONNECT) intervention, in which registered oncology nurses receive specialized training and work closely with oncologists to (1) address symptom needs; (2) engage patients and caregivers in advance care planning; (3) provide emotional support; and (4) coordinate care. The subjects were 23 patients with advanced cancer, 19 caregivers, and 5 oncologists from a community oncology clinic in western Pennsylvania. Feasibility was assessed through enrollment rates, outcome assessment rates, and visit checklists. Patients, caregivers, and oncologists completed three-month assessments of acceptability and perceived effectiveness. Results: The consent-to-approach rate was 86% and enrolled-to-consent rate, 77%. CONNECT was implemented according to protocol for all participants. No participants withdrew after enrollment. Four patients died during the study; three-month outcome assessments were completed with all remaining participants (83%). Patients and caregivers reported high satisfaction with CONNECT and perceived the intervention as helpful in addressing symptoms (85%), coping (91%), and planning for the future (82%). Oncologists unanimously agreed that CONNECT improved the quality of care provided for patients with advanced cancer. Conclusion: An oncology nurse-led care management intervention is feasible, acceptable, and was perceived to be effective for improving provision of primary palliative care. A randomized trial of CONNECT is warranted.
    Journal of Palliative Medicine 12/2014; 49(2). DOI:10.1089/jpm.2014.0325 · 1.91 Impact Factor
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    ABSTRACT: Despite growing concern that institutional review boards (IRBs) impose burdensome delays on research, little is known about the time required for IRB review across different types of research. To measure the overall and incremental process times for IRB review as a process of quality improvement. After developing a detailed process flowchart of the IRB review process, 2 analysts abstracted temporal data from the records pertaining to all 103 protocols newly submitted to the IRB at a large urban Veterans Affairs medical center from June 1, 2009, through May 31, 2011. Disagreements were reviewed with the principal investigator to reach consensus. We then compared the review times across review types using analysis of variance and post hoc Scheffé tests after achieving normally distributed data through logarithmic transformation. Calendar days from initial submission to final approval of research protocols. Initial IRB review took 2 to 4 months, with expedited and exempt reviews requiring less time (median [range], 85 [23-631] and 82 [16-437] days, respectively) than full board reviews (median [range], 131 [64-296] days; P = .008). The median time required for credentialing of investigators was 1 day (range, 0-74 days), and review by the research and development committee took a median of 15 days (range, 0-184 days). There were no significant differences in credentialing or research and development times across review types (exempt, expedited, or full board). Of the extreme delays in IRB review, 80.0% were due to investigators' slow responses to requested changes. There were no systematic delays attributable to the information security officer, privacy officer, or IRB chair. Measuring and analyzing review times is a critical first step in establishing a culture and process of continuous quality improvement among IRBs that govern research programs. The review times observed at this IRB are substantially longer than the 60-day target recommended by expert panels. The method described here could be applied to other IRBs to begin identifying and improving inefficiencies.
    12/2014; 150(2). DOI:10.1001/jamasurg.2014.956

Publication Stats

9k Citations
2,228.55 Total Impact Points


  • 2005-2015
    • Icahn School of Medicine at Mount Sinai
      Borough of Manhattan, New York, United States
    • University of Virginia
      • Division of Maternal Fetal Medicine
      Charlottesville, Virginia, United States
    • Brigham and Women's Hospital
      • Department of Psychiatry
      Boston, Massachusetts, United States
    • University of Washington Seattle
      • Department of Medicine
      Seattle, WA, United States
  • 1989-2015
    • University of Pittsburgh
      • • Division of General Internal Medicine
      • • Department of Medicine
      • • Center for Research on Health Care
      • • Institute for Doctor-Patient Communication
      • • Section of Palliative Care and Medical Ethics
      Pittsburgh, Pennsylvania, United States
  • 2002-2014
    • Duke University
      • Department of Medicine
      Durham, North Carolina, United States
  • 2012-2013
    • UPMC
      Pittsburgh, Pennsylvania, United States
  • 2002-2011
    • Massachusetts General Hospital
      Boston, Massachusetts, United States
  • 2010
    • University of Wisconsin–Madison
      Madison, Wisconsin, United States
    • The Harvard Drug Group
      Ливония, Michigan, United States
  • 2009
    • University of Pennsylvania
      • Center for Health Equity Research
      Philadelphia, PA, United States
  • 2008
    • The Children's Hospital of Philadelphia
      Filadelfia, Pennsylvania, United States
    • Johns Hopkins University
      Baltimore, Maryland, United States
    • University of Rochester
      • Center for Ethics, Humanities, and Palliative Care
      Rochester, New York, United States
  • 2007
    • University of California, Irvine
      Irvine, California, United States
    • Harvard Medical School
      Boston, Massachusetts, United States
    • George Washington University
      Washington, Washington, D.C., United States
  • 2004-2007
    • Dana-Farber Cancer Institute
      • Department of Psychosocial Oncology and Palliative Care
      Boston, MA, United States
    • University of Toronto
      Toronto, Ontario, Canada
    • Duke University Medical Center
      • Department of Medicine
      Durham, North Carolina, United States
    • Hospital of the University of Pennsylvania
      • Department of Medicine
      Filadelfia, Pennsylvania, United States
  • 2003
    • Case Western Reserve University
      • Department of Bioethics
      Cleveland, OH, United States
  • 1993-2003
    • Harvard University
      Cambridge, Massachusetts, United States
  • 2000
    • Johns Hopkins Bloomberg School of Public Health
      Baltimore, Maryland, United States
    • Concordia University–Ann Arbor
      Ann Arbor, Michigan, United States
  • 1995
    • United States Department of Veterans Affairs
      Бедфорд, Massachusetts, United States