Interview with Dr. Christian Zouain – 330
In today's episode, John revisits the hospital CDI career with Dr. Christian Zouain. He was first interviewed in March of 2019.
We explore the fascinating world of Clinical Documentation Integrity (CDI) through the lens of Dr. Zouain, a seasoned professional in the field. Whether you are a seasoned CDI professional or someone considering a career shift, Dr. Zouain's experiences serve as a valuable resource. His journey reflects the changing face of CDI, and the diverse career pathways available within this field.
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Dr. Christian Zouain's Journey into Clinical Documentation Integrity (CDI)
Dr. Christian Zouain reflects on his transition from medical school in the Dominican Republic to his involvement in CDI in the United States. He shares insights into the significance of CDI in healthcare, his initial encounters with physicians, and the evolving role of clinical documentation.
Significance of CDI in Healthcare
Clinical Documentation Improvement (CDI) significantly enhances healthcare quality by ensuring accurate and detailed medical documentation. It thereby improves patient safety, reduces errors, and promotes effective communication among healthcare providers enhancing care coordination.
Evolving Role of Clinical Documentation
In Christian's encounters with physicians, he discovered the evolving role of clinical documentation. What started as expertise needed to optimize payments, later became a critical understanding of how to demonstrate the quality of care. With annual updates published by CMS, the CDI expert must continually update their knowledge base.
From Clinical Documentation Improvement to Denials and Appeals
Dr. Zouain sheds light on the transformation of CDI from Clinical Documentation Improvement to Clinical Documentation Integrity. He explains the crucial role CDI professionals play in ensuring accurate and complete clinical records. Additionally, he explains how his knowledge of CDI enabled his professional growth in the area of denials and appeals.
Summary
Dr. Christian Zouain can be contacted through his LinkedIn profile. For information about job openings and updates, Acuity Healthcare's official website is a valuable resource. Dr. Zouain also recommends following Acuity on LinkedIn for the latest job postings. If you pursue a job, please be sure to mention Dr. Zouain to the recruiter.
If you have additional questions about this career or pursuing your first position, he encourages you to reach out directly to him.
NOTE: Look below for a transcript of today's episode.
EXCLUSIVE: Get a daily dose of inspiration, information, news, training opportunities, and amusing stories by CLICKING HERE.
Links for Today's Episode:
- Dr. Christian Zouain's LinkedIn profile
- Acuity Healthcare
- Why CDI Medical Director Is a Great Nonclinical Job – 224
- PNC Podcast Blast from the Past: Clinical Documentation Improvement – 206
- Top Reasons to Become a CDI Expert with Dr. Christian Zouain – 077
- NewScr!pt
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Transcription PNC Podcast Episode 330
Follow This Plan to Establish a Solid Hospital CDI Career
- Interview with Dr. Christian Zouain
John: I wanted to bring back today's guest for several reasons. First of all, his story is very fascinating. Now, he was here in a previous episode in March of 2019. You can learn more about that at that episode, and I'll put a link to that. But he has a really fascinating story about how he became a hospital CDI expert.
I wanted him to come back because I personally think that a CDI specialist is really critical to hospitals functioning. I don't know how any hospital cannot do what they do and get paid appropriately and so forth without using a CDI specialist in some way. And I think it's a position that's often underappreciated and some of you should really consider that. So, welcome back to the show, Dr. Christian Zouain.
Dr. Christian Zouain: Thank you for having me again. It's great to be here.
John: I just remember our session back, those whatever, four or five years ago. I always loved CDI when I was working in the hospital environment, number one. And number two, it was so interesting to hear how you had gotten involved with CDI. And we'll define what CDI is in a minute. Why don't you, for our listeners, just give us the thumbnail sketch about your background and how you first got into the CDI business.
Dr. Christian Zouain: Yeah. The resumed version would be, I graduated from medical school back in the Dominican Republic in 2010. Initially, my plans as every other doctor, especially foreign doctors, who has a vision to come into the US is taking the USMLE. I practiced for a few years while I studied for the boards, and then I moved to New York, and I started getting into roles in the healthcare system. While I studied that way, I could also meet some people, network and all that to get my way through the residency process.
While I did that, I started finding out about these opportunities that were available. And it wasn't after I would say two or three years in that I found out about coding, clinical documentation improvement, the value it brought to healthcare, the importance is has for our health systems, and the well of our whole community.
I said, "You know what? There's something here. This is something that I can see myself doing. This is something that has value and that it will eventually continue to grow." And it's been already eight years. I've been doing this seven, eight years. So it's been great. It's been just as my original mentors had originally told me, listen, if you get into this, if you get the basics, there's so much you can do. There's so many pathways you can take. There's so many ways you can help within the industry to make things better, help the doctors, help the facilities, and eventually help the patients, which is the main reasons why we came into medicine, is to help our patients. That's one of the other good things that we are helping our patients in a good way by doing this work.
John: Yeah, it seems like a lot of these things that we do, whether it's utilization management or informatics or quality or CDI. Ultimately, the bottom line is to get the patient's care taken care of, pay for it, approve it, allow them to stay in the hospital or not stay in the hospital. There's lots of these things that we have to do to make sure they get the care that they need.
Tell us the technical, what does CDI mean now. When I was back in the hospital whatever, nine, 10 years ago is always called clinical documentation improvement. But I think you've kind of evolved that to a different definition now.
Dr. Christian Zouain: Yeah. It has evolved. They changed the last part, which now it's considered, they want to call it clinical documentation integrity, which we just want to make sure that we get the actual most complete accurate picture of that clinical scenario that happened in the hospital for that patient, translated into the record so the hospital, the physicians, and the entire health system gets reimbursed the proper amount of what went on that particular visit.
That's what the basics of CDI is. We're just trying to be of help, be that middleman between the physician and the coding expert, which is something that we don't really learn when we're in school. We tend to learn about this where when you're in residency or you start working in the hospital. Obviously like 10 years ago, I remember when I started something that physicians, they found a bit irritating. Someone's coming up to you, asking you all these, I would say dumb questions.
I even remember taking that as one of my approaches, when going to talk to one of the physicians saying, "Hey, doc. This is a really stupid question that I'm going to ask you, but I need to know this." That way I would be able to get that closeness and that reaction from that physician and I would get the information I needed.
But yeah, it has evolved. Gratefully, a lot of physicians have understood the importance, that this is not something that we're trying to question them or something that we're just trying to mess around. Sometimes I explain to someone that it's not the industry, like it's a game because it's something that it's a process that the insurance has, coding has, and then the hospital has its own process.
We're trying to manage on a day by day basis how to get everyone along. It's like getting all these rules together, getting everyone to understand each other. It's not like something that's going to be clear cut eventually that it's going to be fixed. No, it's something that it's still taking time. It's a process. And rules change every day.
John: I've heard in the past a metaphor where somebody was trying to describe this to me, and they talked about Michael Jordan and basketball or whatever. It could be anybody. But the thing is, games have rules. And you got to know where you can go in terms within the rules and do it right. But even in basketball, should you fouled out, should you not? That's a strategic decision. And you have to know the rules when you're playing a game or you're never going to win at the games. This is another one of those examples.
Now, one of the things that they used to tell me back in the day when we first heard about CDI and the importance of documenting and getting everything down to the last issue in terms of someone's preexisting conditions or president of admission. I don't even know if they call that anymore. But because most of the quality measurement of hospitals is based on billing data, then again, this is another reason why CDI is so important because there's a risk adjustment. And so, tell us about that. Is that still true?
Dr. Christian Zouain: Yeah, absolutely. Every day, again, it still holds true. That was the main reason why the billing process was shifted towards from pay for service, pay for performance. We're paying for the quality of service, the patient experience. How well was that patient treated, not based on the amount of procedures that the patient had. That's why we have the different billing systems, the MS DRG, the APR DRG. We have those in place. And that's the main focus of those. It's shifting that process of payment towards that, because eventually the quality, it's what's going to drive that payment factor.
We just want to make sure that the patient's reflected correctly, that we don't bill for things that happened in the hospital present on admission, of course, that's still something that holds true today. If you came in with something, everything has to be specified as being, okay, did the patient come in with this? Because if the patient had a fall and had a fracture eventually in the hospital, that code by itself can actually shift towards something that increases the bill. And you want to say, okay, if just by shifting that POA code present on admission indicator, shifting it from "yes" to "no" can make a huge difference on the payment.
Something I didn't mention to you earlier, which is now I'm not doing the actual clinical documentation improvement part. I'm working more in the denials and appeals part. I did a lateral shift, and I've been able to see a lot of these things that I would query initially, like coming back. That's one of the main reasons why I wanted to do that, to make that change. Because I wanted to see eventually, okay, is the insurance company really accepting what I'm having these doctors, that document in these records? How are they internalizing it? How are they fighting it back?
I do remember the other day, there was something that I didn't know, it was something about a procedure that the patient had a complication, and they said the doctor clearly said that this was a complication, and it wasn't coded as a complication, and it made a huge difference on the payment. And I said, you know what? They're right. I don't usually agree with what they said, but this is one of those instances where I say, you know what? I didn't know this, but it's interesting how these small factors come into play, the present on admission, quality indicators, anything that happens in the hospital, that make a difference in that payment, how it changes.
John: Yeah. That's why when I think back about my days in the hospital, we probably had at least every two or three years another consulting firm come in. And I don't know that there were these big companies, maybe Acuity was around and some others, but usually just people come in to help us bolster, improve our CDI program. It just amazed me that there were hospitals that still didn't have really even a dedicated nurse or physician even focusing on that. So, it kind of blew my mind. Although I have a question I have for you. Does it seem like the physicians coming out of training, residency and fellowship, do they have a better understanding of this now than they did five or 10 years ago?
Dr. Christian Zouain: Yes, I believe so. Yeah. I definitely think so, especially because just like you said, with let's say the rise of having these consulting companies, like Acuity, the one I work for is something of so much importance because when you have it on site, it is important. You have that person that the doctor can relate to. They know which doctor to go to.
But sometimes even if you're part of a big health system, because I worked in different hospitals, large health systems, small hospitals, and it's hard when you don't have that I would say that support, because you don't know it all. All these rules are very complex. You have the clinical part, but you also are continuing to learn the coding part. So you're trying to do your best.
Now, the doctors, when they see this, it's like, okay, sometimes you might make a mistake or they might think you're a little bit obnoxious. They don't want to really sit down with you and answer to all these nonsense questions. But with these companies now you have these group of professionals that they're all in tune. Even if you're not sure, for example, the model of acuity is you have a physician, which is a medical director position with an expert coder going into the case firsthand reviewing the entire case. So, you have an expert in clinical and an expert in coding reviewing that case.
Next part is they capture the opportunity, they send it over to someone like me, that was my position initially when I started in Acuity, which is the query writer. I would write the query based on the information they provided.
Now, when you have a more effective system, I would say it works better. I think physicians are able to accept it more with more ease. When they have a solid professional asking them questions and explaining to them in the right way, why are they asking the questions? This is the reason why we're doing this. We can show you in the code book. Or you also have administration behind supporting the consulting company.
And they're not just saying we're doing this for the money. No. These are companies like Acuity, and I don't know other consulting companies, but we go on site and we provide education to the physicians on how our process works. And we also give them education on them based on whatever issues we find recurring in their facility, why we are asking these questions, and how it translate into the coding and it translate into the payment and the quality metrics. That's been a huge part in answering your question. I know it's been a little bit lengthy, but yeah, I think that the physicians in these years have adapted more to the role because of the search of these consulting positions definitely.
John: Well, that's a good segue to talk about not so much CDI itself as an entity, as a domain to learn about, but what are the jobs in the CDI? Because I think you've held a number, and I don't remember exactly what you were doing before within CDI, but I know there are remote positions now a lot more probably since the pandemic, but then you have to go on site sometimes. Sometimes you're employed by a hospital system directly. Sometimes you're employed by a company that does the outsourcing. So, what's kind of the range of jobs out there that listeners might say, "Oh, this does sound interesting, this one's got the flexibility I might need?" Maybe give us an overview of that.
Dr. Christian Zouain: Yeah. It all starts with the coding. When I started, again, you have the clinical part and then you need to learn about the coding. And with that, basically, you can go into CDI. Again, I did a lateral move into appeals and denials, but as far as I know, it's coding, CDI, you can do inpatient, you can do outpatient within the realm of CDI. Then you have the different ramifications, which is you can focus more on a specific aspect. You can go more into education. You can be a director in a hospital. You can become a physician advisor. Going by what we have in Acuity, from what I know, just like I said, we have the medical director positions. But then we have educators, we have the people that go on site. We have query closers, we have query writers, we have appeal writers. The coding world is very, very, very, diverse. Just in the inpatient setting, there's a lot of ways you can go.
I remember about three or four years ago, the outpatient, CDI, was coming up and I said, "You know what? I think this is going to be like the future of this because I know a lot of procedures are being done like outpatient, eventually inpatient is going to be." And that was about for a year, two years. That was something that was really booming. But eventually, it has grown, but I've stayed in the inpatient setting. As far as I know, in Acuity we do mostly inpatient. And again, I went into doing appeals now, which I like even more because I get to see, I feel like I am using that knowledge again, and justifying why that service has to be covered or that diagnosis is valid using my knowledge and my expertise in coding in clinical and CDI.
John: Let me ask you this. Talking about specifically your role now in the denials and the appeals and so forth, are they looking at making an alteration in the principle diagnosis? Are they looking at whether the MS-DRG comes in three levels for most diagnoses? Is it that? What are the kind of things that actually get appealed in which you have to provide clarity when you can?
Dr. Christian Zouain: Yeah. In Acuity so far we only do clinical validation and MS-DRG appeals and denials. We receive changes in principal diagnosis, whether it is clinically valid or not. We receive request to change coding based on coding rules. Coding rules, which are sometimes more complex. Like this diagnosis were based on this guideline, it's supposed to be the correct principle diagnosis instead of this one.
And present on admission indicators, but mostly it's clinical validation. Clinical validation denounce is what we get the most. Sepsis. They use a lot of the argument now that sepsis three to one that has to be used, but the facility hasn't placed the rule, the guideline that still used the sepsis two. So we have to argue that okay, although sepsis three was put into place, they don't use that. So, we have to defend it on that end. Or the patient didn't really have an increase in creatinine of more than 0.3 to be considered AKI, but the doctor wrote it consistently throughout the record. Those things are the ones we fight every day mostly. It's mostly that validation of diagnosis that they feel like the diagnosis are not clinically valid.
John: Now, when you say appeals and denials and fighting these things, I have a friend that works at a local hospital. And on the UM side, he's getting on a conference call with an administrative law judge and other people on their side and Medicare side and their people on the hospital side. Is it like that? How do you do these appeals? Who are you appealing to?
Dr. Christian Zouain: No. We received the letters directly from the auditor or the insurance company. We receive letters and the letters have their own rationale. We provide the information, we make a document and we just send it back to the hospital.
John: So, it's a written appeal.
Dr. Christian Zouain: Right. It's a written appeal. We send back to the facility. The facility is in charge. I put my signature on it with Acuity's name, and then they send it over to the corresponding auditor. But then after, we might have several levels, but after it's exhausted how we call it, that's up to the hospital to decide if they want to escalate on their own part. If they want to have a peer-to-peer with their doctor and discuss that at that point. The hospital takes care of that. We are only part of I would say three levels of written appeals. We only do it in writing.
John: Got it. Got it. Yeah. This gets all very confusing because we can throw out a term and say there's always different jobs available, but Acuity does things one way, and there's probably 10 other firms that do other things and the hospital is doing its thing. But just to give us a glimpse in the time you've been doing this, both as in the denials and even before, are these the kind of jobs that are pretty much done remotely? Does it require checking into the office and showing up in person? Is it something you can do on your own time? Is it 9:00 to 05:00? Just give us some of the constraints on these kind of positions in terms of the time and the travel and so forth.
Dr. Christian Zouain: Yeah. When we first did the first interview a few years ago, I had just started with Acuity. And at that time, I do remember that I knew when I found them, I was like, "Wow, this is amazing." Because it was actually the first company I knew that it was 100% remote, and they were hiring foreign medical graduates. Other companies would require you to have an RN license, or some sort of license to work, which I found a bit strange because I was like, really? I'm doing work from home and it's documentation. I'm not really writing a script or anything like that.
But I do believe, especially when COVID hit, when the pandemic hit, a lot of other industries they had to go into fully remote or part-time remote. Then they just basically realized that it was doable.
This work can be done 100% remote. My company Acuity, it's been 100% remote. When I started, the only thing that I had to be present for was the training, which I had to go to the main office in New York to meet with, we had to get all the access and do everything. But during the pandemic that switched. So, the training is now being done just the same way, like any other presentation that's done in the company. It's done via Zoom or Teams. It's done remotely. It's 100% remote.
Now, I do know there are probably other facilities when you have your onsite DDI program, they probably still have it. I know some of them are maybe half and half. You would go several days to the hospital so they can see you and the other days you can work from home because you have access to the electronic health record through your computer at home.
But yeah, eventually I think mostly the ones that are still in the hospital, they are still require some sort of presence. And that's good because I think that's one of the benefits of doing the onsite. I had that I would say that privilege of doing that initially when I started, which it was 100% on site, and the hospital I used to work for was hybrid. They still had part of the records in paper charts.
So, it wasn't something that we could even argue like, "Hey, listen, can we do one day from home?" No, that was out of the question because they were still on paper and we had to go to the floor. But that helps you a lot to build that, to break out of that shell, I would say, to get close to the physicians, have a conversation, get to understand what's really going on with the patient, get their view. And also they learn from you in terms of, "Hey, listen, this is why I'm asking you because this documentation translates into this." Now with being 100% remote, you can't do that. After I started working with Acuity, my contact, when I was writing queries, I would talk to a doctor maybe once every two months. And it was because they would call me, they would see my name on the query, but they weren't really supposed to. They were someone else in a different department who would take care of that. Whereas when I was in the hospital, it was constantly, for every single query I sent, I had to talk to the physicians.
John: Yeah. Interesting. It has evolved quite a bit. I was talking to someone who does UM. He is relatively new, but it was kind of the same thing. He's in a system and they didn't really have a pretty robust UM program. He was assigned and he took a job as a medical director, and there were multiple sites, but he was doing half of it remote because he couldn't drive hundred miles in a day to hit every hospital. He'd do some of it remote, and then sometimes he had to show up and meet the physicians, and he really thought that helped. But I could see him migrating at some point to a 100% remote job with a big company because the lifestyle is so much better.
And so, would you say in general that most physicians are going to be very happy with working in CDI at one of these companies in terms of the lifestyle, the pay and vacation and opportunities for advancement?
Dr. Christian Zouain: Yeah, absolutely. Absolutely. The shift that I've seen and the opportunities just like I've seen in my own work environment, even though I don't interact as much. The company right now from the last town hall, they said we had about 600 employees nationwide. They did implement some sort of activity that we would do. Everyone that lives in the same state or close by, like in the same city, they would get together. I was able to meet a few of the doctors that work for the company as well and other coders. One of them was head of IT education portion of Acuity.
The others, they were directors of coding. There's a lot of opportunities still out there. I think much more that than what I know of, but definitely, again, just like I said, knowing the craft can get you towards getting a lot of opportunities in the field. And I've seen that. I would continue to encourage everyone that likes it and finds the value in it. It's really a good career. And all the companies, just like the one I work for, they're doing a great job and they're growing, expanding, and they're doing a lot of great things.
John: Excellent. That's good to hear. We want to have as many opportunities for our physicians as possible as they decide to transition to something maybe out of clinical that they're doing now or something like that.
We are going to run out of time. We're probably getting close to the end here. Real quickly, if someone is currently in practice, maybe they're doing some inpatient so they have exposure to that part of it, what would you advise them is how to start to look at making that transition? They just start looking up jobs, or is there something they can do in the meantime to set them up to succeed if they decide to apply for a job like this with one of the companies that does the remote CDI activities?
Dr. Christian Zouain: Yeah, I would say it would be the same advice I gave on the first part podcast. Again, you basically have the clinical knowledge part. Just get into knowing more about the coding aspect, how it works. Maybe do a coding course geared toward maybe a certification like a CCS. That's one I would say. For example, there's several coding certifications, but the CCS, it's like the more expert one. But for us physicians, to be honest, it's something that it's not that hard to acquire because we already handle all the terms, all the clinical terms. We just have to know all the coding rules and games, again, like we mentioned earlier.
After that, again, I know that Acuity has that particularly that the medical director position, the doctors they hire, they do have some coding, clinical background, but they don't need to be really like coding experts per se because they're looking more toward the clinical part and having a basic understanding of the coding part. And along with the coding director and with the company itself, you're going to be able to start learning everything and grasping. Because again, every company does everything on their own way.
There's not a specific way. Just like every hospital, CDI program does things a certain way. I know this because since I've worked for different facilities, one might think, "Oh, well, maybe when I go to this next job or this next facility, they might think I don't know how to do it because we did it differently."No, everyone in the industry is very aware that every facility has their own ways of doing things, but the core of everything is knowing the basics of medical coding and how it works. Other than that, it's just a matter of time and experience. Even till this day, I don't know everything, I don't think I'll ever know everything because again, there's a lot out there and everything changes from time to time, but it's a constant process.
There are certain things that are the main focus. There's always opportunities for sepsis, for acute kidney injury. There's diagnoses that are pretty common, for example. There's commonalities on every industry. But that would be my advice. Getting to coding and reach out to other colleagues that are doing the same thing, either in your hospital or through LinkedIn.
Right now, I do remember someone that reached out to me. I think it was who listened to your podcast about a year ago. I do remember she told me. I'm glad she listened to the episode. And a year later she messaged me again, and she told me, I just wanted to let you know that I was just hired in your company. And I didn't know. She actually went on her way. I think she got a coding certification, and she met someone else from the company through LinkedIn. And I think they established a friendship. And she was able to get hired for her first job in CDI 100% remote, which was something that if you would've asked me, probably like five years ago, I would've said no. You have to start maybe on a hospital, that they give you an opportunity on onsite. But now, it's possible. There's a lot of opportunity out there. There's a lot of facilities. You can reach to a lot of people.
John: Plus the power of networking.
Dr. Christian Zouain: Yeah.
John: It's like meeting people, getting advice, getting mentors and talking about their company. Who do I apply to? Is there someone I can talk to? There's so many little tricks you can do too along the way.
First I want to say that you're on LinkedIn, obviously, as you mentioned. Just look Christian Zouain up, or if you want to use the URL, I think it's linkedin.com/in/christianzouain. It's hard to miss you really. There aren't that many other Christian Zouains around. I don't think. I do see though on your LinkedIn frequently you'll post that your company has openings. I could put you on the spot now and say, are there openings there? And if someone has a question about an opening, they can just go ahead and apply, but I suppose it'd be okay to contact you and ask you a little bit more about it.
Dr. Christian Zouain: Yeah, definitely, if anyone is interested. As soon as I see any posts from HR or anything, I would do a repost just so anyone can see. If anyone has any questions, again, just like you mentioned earlier, I want to emphasize just like we did. I know we did on the first podcast interview, like networking that is very important, not just for this industry, for anything that anyone would want to do or pursue. The power of networking, it's very powerful. I would say reach out. Don't be afraid to reach out to anyone for advice. If you don't get a response from someone just move to the next one. There's a bunch of people. Look for someone that works in the company you want to work for and try to establish a connection with them. But if you see me reposting or you can go to Acuity's website, acuityhealthcare.com, or follow them on LinkedIn, they usually post the open positions there. If you have any questions on that, you can reach out to me. Just to throw it in there, we have a referral program. If you want to mention my name, just to put it out there, you can also do so.
But yeah, I'm available for any questions that you might have, any orientation that I can provide. By doing this, what I'm trying to do is be the person that I wish I could have found when I first started, because there was not a lot of people out there. Yesterday I spoke to, there was someone that came to my house. He's a nurse. He works as a nurse in the hospital, but then he's a doctor back in Brazil. And he was telling me. He came in, he did the process of getting his RN license and all of that. I was telling him what I did, and he was impressed because he said, "You know what? I've been doing this. I've been working here 15 years and I've never heard of what you do." And I said, "Really?" And he was like, yeah.
We talked for a while and I said write down my phone number. I send him the presentation I've had that I did back to do the Medical Association to that group of doctors. Because still, sometimes I'm impressed by the fact that these opportunities are really not out there so people can see them. Even if they're in the hospital, if they don't find the right person, some people maybe they keep more to themselves and all that, but whenever I find a colleague and they tell me they're a foreign doctor or a doctor that is trying to do residency, I tell them what I do, because you never know. And also I'm always open to give advice or even not just give advice, also learn, because I can learn from the other person as well.
John: I know there's at least a thousand physicians and other clinicians who eventually will listen to this episode. And so, I'm going to tell you that if you have any linkage whatsoever with a hospital or with documentation, coding, patient care, and if you're actually practicing, of course, you're exposed every day, then this is an opportunity. There's a huge need. It's a good lifestyle, and you're applying your medical background. And so, what could be better?
And the other thing is I don't apologize about maybe having someone mention that you referred them to your employer, because guess what people? I'm talking to my listeners now. All my guests come on for free. They take their time, they share because they're professionals or physicians, most of them, and they want other physicians to prosper and succeed and be happy in their careers, not be miserable doing corporate style healthcare seeing 50 patients a day and working all weekend. The least you can do is if you contact Acuity that you mentioned Dr. Zouain's name just as a little bit of a bonus for taking the time to share his information with us. So I do appreciate that, Christian.
Dr. Christian Zouain: No, thank you. Thank you for allowing me to be on your platform.
John: Basically Christian is agreeing to be your informal mentor. And by the way, if you need a mentor in the future, I always remind my listeners too. A mentor is not someone you're going to sit down for three hours with and take up all their time. A mentor is someone you just go to, you send them a note, or you have a brief conversation, ask them a question, and boom, you just take their advice and move on. And then maybe reconnect again three or six months later. We're not talking about intense coaching here. We're talking about just networking and communicating and getting a little bit of free advice.
Dr. Christian Zouain: Absolutely.
John: All right, Christian. I guess it's time to go. I really appreciate you being here today. It's been fun. I've enjoyed catching up and learning from you, again, more about CDI since I was involved with it over 10 years ago. I'm sure we can reconnect again down the road. Again, thanks for being here today.
Dr. Christian Zouain: Definitely. Thanks a lot, Dr. Jurica.
John: All right. With that, I will say goodbye.
Dr. Christian Zouain: All right. Take care. Bye.
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Transcription PNC Podcast Episode 330
Follow This Plan to Establish a Solid Hospital CDI Career
- Interview with Dr. Christian Zouain
John: I wanted to bring back today's guest for several reasons. First of all, his story is very fascinating. Now, he was here in a previous episode in March of 2019. You can learn more about that at that episode, and I'll put a link to that. But he has a really fascinating story about how he became a hospital CDI expert.
I wanted him to come back because I personally think that a CDI specialist is really critical to hospitals functioning. I don't know how any hospital cannot do what they do and get paid appropriately and so forth without using a CDI specialist in some way. And I think it's a position that's often underappreciated and some of you should really consider that. So, welcome back to the show, Dr. Christian Zouain.
Dr. Christian Zouain: Thank you for having me again. It's great to be here.
John: I just remember our session back, those whatever, four or five years ago. I always loved CDI when I was working in the hospital environment, number one. And number two, it was so interesting to hear how you had gotten involved with CDI. And we'll define what CDI is in a minute. Why don't you, for our listeners, just give us the thumbnail sketch about your background and how you first got into the CDI business.
Dr. Christian Zouain: Yeah. The resumed version would be, I graduated from medical school back in the Dominican Republic in 2010. Initially, my plans as every other doctor, especially foreign doctors, who has a vision to come into the US is taking the USMLE. I practiced for a few years while I studied for the boards, and then I moved to New York, and I started getting into roles in the healthcare system. While I studied that way, I could also meet some people, network and all that to get my way through the residency process.
While I did that, I started finding out about these opportunities that were available. And it wasn't after I would say two or three years in that I found out about coding, clinical documentation improvement, the value it brought to healthcare, the importance is has for our health systems, and the well of our whole community.
I said, "You know what? There's something here. This is something that I can see myself doing. This is something that has value and that it will eventually continue to grow." And it's been already eight years. I've been doing this seven, eight years. So it's been great. It's been just as my original mentors had originally told me, listen, if you get into this, if you get the basics, there's so much you can do. There's so many pathways you can take. There's so many ways you can help within the industry to make things better, help the doctors, help the facilities, and eventually help the patients, which is the main reasons why we came into medicine, is to help our patients. That's one of the other good things that we are helping our patients in a good way by doing this work.
John: Yeah, it seems like a lot of these things that we do, whether it's utilization management or informatics or quality or CDI. Ultimately, the bottom line is to get the patient's care taken care of, pay for it, approve it, allow them to stay in the hospital or not stay in the hospital. There's lots of these things that we have to do to make sure they get the care that they need.
Tell us the technical, what does CDI mean now. When I was back in the hospital whatever, nine, 10 years ago is always called clinical documentation improvement. But I think you've kind of evolved that to a different definition now.
Dr. Christian Zouain: Yeah. It has evolved. They changed the last part, which now it's considered, they want to call it clinical documentation integrity, which we just want to make sure that we get the actual most complete accurate picture of that clinical scenario that happened in the hospital for that patient, translated into the record so the hospital, the physicians, and the entire health system gets reimbursed the proper amount of what went on that particular visit.
That's what the basics of CDI is. We're just trying to be of help, be that middleman between the physician and the coding expert, which is something that we don't really learn when we're in school. We tend to learn about this where when you're in residency or you start working in the hospital. Obviously like 10 years ago, I remember when I started something that physicians, they found a bit irritating. Someone's coming up to you, asking you all these, I would say dumb questions.
I even remember taking that as one of my approaches, when going to talk to one of the physicians saying, "Hey, doc. This is a really stupid question that I'm going to ask you, but I need to know this." That way I would be able to get that closeness and that reaction from that physician and I would get the information I needed.
But yeah, it has evolved. Gratefully, a lot of physicians have understood the importance, that this is not something that we're trying to question them or something that we're just trying to mess around. Sometimes I explain to someone that it's not the industry, like it's a game because it's something that it's a process that the insurance has, coding has, and then the hospital has its own process.
We're trying to manage on a day by day basis how to get everyone along. It's like getting all these rules together, getting everyone to understand each other. It's not like something that's going to be clear cut eventually that it's going to be fixed. No, it's something that it's still taking time. It's a process. And rules change every day.
John: I've heard in the past a metaphor where somebody was trying to describe this to me, and they talked about Michael Jordan and basketball or whatever. It could be anybody. But the thing is, games have rules. And you got to know where you can go in terms within the rules and do it right. But even in basketball, should you fouled out, should you not? That's a strategic decision. And you have to know the rules when you're playing a game or you're never going to win at the games. This is another one of those examples.
Now, one of the things that they used to tell me back in the day when we first heard about CDI and the importance of documenting and getting everything down to the last issue in terms of someone's preexisting conditions or president of admission. I don't even know if they call that anymore. But because most of the quality measurement of hospitals is based on billing data, then again, this is another reason why CDI is so important because there's a risk adjustment. And so, tell us about that. Is that still true?
Dr. Christian Zouain: Yeah, absolutely. Every day, again, it still holds true. That was the main reason why the billing process was shifted towards from pay for service, pay for performance. We're paying for the quality of service, the patient experience. How well was that patient treated, not based on the amount of procedures that the patient had. That's why we have the different billing systems, the MS DRG, the APR DRG. We have those in place. And that's the main focus of those. It's shifting that process of payment towards that, because eventually the quality, it's what's going to drive that payment factor.
We just want to make sure that the patient's reflected correctly, that we don't bill for things that happened in the hospital present on admission, of course, that's still something that holds true today. If you came in with something, everything has to be specified as being, okay, did the patient come in with this? Because if the patient had a fall and had a fracture eventually in the hospital, that code by itself can actually shift towards something that increases the bill. And you want to say, okay, if just by shifting that POA code present on admission indicator, shifting it from "yes" to "no" can make a huge difference on the payment.
Something I didn't mention to you earlier, which is now I'm not doing the actual clinical documentation improvement part. I'm working more in the denials and appeals part. I did a lateral shift, and I've been able to see a lot of these things that I would query initially, like coming back. That's one of the main reasons why I wanted to do that, to make that change. Because I wanted to see eventually, okay, is the insurance company really accepting what I'm having these doctors, that document in these records? How are they internalizing it? How are they fighting it back?
I do remember the other day, there was something that I didn't know, it was something about a procedure that the patient had a complication, and they said the doctor clearly said that this was a complication, and it wasn't coded as a complication, and it made a huge difference on the payment. And I said, you know what? They're right. I don't usually agree with what they said, but this is one of those instances where I say, you know what? I didn't know this, but it's interesting how these small factors come into play, the present on admission, quality indicators, anything that happens in the hospital, that make a difference in that payment, how it changes.
John: Yeah. That's why when I think back about my days in the hospital, we probably had at least every two or three years another consulting firm come in. And I don't know that there were these big companies, maybe Acuity was around and some others, but usually just people come in to help us bolster, improve our CDI program. It just amazed me that there were hospitals that still didn't have really even a dedicated nurse or physician even focusing on that. So, it kind of blew my mind. Although I have a question I have for you. Does it seem like the physicians coming out of training, residency and fellowship, do they have a better understanding of this now than they did five or 10 years ago?
Dr. Christian Zouain: Yes, I believe so. Yeah. I definitely think so, especially because just like you said, with let's say the rise of having these consulting companies, like Acuity, the one I work for is something of so much importance because when you have it on site, it is important. You have that person that the doctor can relate to. They know which doctor to go to.
But sometimes even if you're part of a big health system, because I worked in different hospitals, large health systems, small hospitals, and it's hard when you don't have that I would say that support, because you don't know it all. All these rules are very complex. You have the clinical part, but you also are continuing to learn the coding part. So you're trying to do your best.
Now, the doctors, when they see this, it's like, okay, sometimes you might make a mistake or they might think you're a little bit obnoxious. They don't want to really sit down with you and answer to all these nonsense questions. But with these companies now you have these group of professionals that they're all in tune. Even if you're not sure, for example, the model of acuity is you have a physician, which is a medical director position with an expert coder going into the case firsthand reviewing the entire case. So, you have an expert in clinical and an expert in coding reviewing that case.
Next part is they capture the opportunity, they send it over to someone like me, that was my position initially when I started in Acuity, which is the query writer. I would write the query based on the information they provided.
Now, when you have a more effective system, I would say it works better. I think physicians are able to accept it more with more ease. When they have a solid professional asking them questions and explaining to them in the right way, why are they asking the questions? This is the reason why we're doing this. We can show you in the code book. Or you also have administration behind supporting the consulting company.
And they're not just saying we're doing this for the money. No. These are companies like Acuity, and I don't know other consulting companies, but we go on site and we provide education to the physicians on how our process works. And we also give them education on them based on whatever issues we find recurring in their facility, why we are asking these questions, and how it translate into the coding and it translate into the payment and the quality metrics. That's been a huge part in answering your question. I know it's been a little bit lengthy, but yeah, I think that the physicians in these years have adapted more to the role because of the search of these consulting positions definitely.
John: Well, that's a good segue to talk about not so much CDI itself as an entity, as a domain to learn about, but what are the jobs in the CDI? Because I think you've held a number, and I don't remember exactly what you were doing before within CDI, but I know there are remote positions now a lot more probably since the pandemic, but then you have to go on site sometimes. Sometimes you're employed by a hospital system directly. Sometimes you're employed by a company that does the outsourcing. So, what's kind of the range of jobs out there that listeners might say, "Oh, this does sound interesting, this one's got the flexibility I might need?" Maybe give us an overview of that.
Dr. Christian Zouain: Yeah. It all starts with the coding. When I started, again, you have the clinical part and then you need to learn about the coding. And with that, basically, you can go into CDI. Again, I did a lateral move into appeals and denials, but as far as I know, it's coding, CDI, you can do inpatient, you can do outpatient within the realm of CDI. Then you have the different ramifications, which is you can focus more on a specific aspect. You can go more into education. You can be a director in a hospital. You can become a physician advisor. Going by what we have in Acuity, from what I know, just like I said, we have the medical director positions. But then we have educators, we have the people that go on site. We have query closers, we have query writers, we have appeal writers. The coding world is very, very, very, diverse. Just in the inpatient setting, there's a lot of ways you can go.
I remember about three or four years ago, the outpatient, CDI, was coming up and I said, "You know what? I think this is going to be like the future of this because I know a lot of procedures are being done like outpatient, eventually inpatient is going to be." And that was about for a year, two years. That was something that was really booming. But eventually, it has grown, but I've stayed in the inpatient setting. As far as I know, in Acuity we do mostly inpatient. And again, I went into doing appeals now, which I like even more because I get to see, I feel like I am using that knowledge again, and justifying why that service has to be covered or that diagnosis is valid using my knowledge and my expertise in coding in clinical and CDI.
John: Let me ask you this. Talking about specifically your role now in the denials and the appeals and so forth, are they looking at making an alteration in the principle diagnosis? Are they looking at whether the MS-DRG comes in three levels for most diagnoses? Is it that? What are the kind of things that actually get appealed in which you have to provide clarity when you can?
Dr. Christian Zouain: Yeah. In Acuity so far we only do clinical validation and MS-DRG appeals and denials. We receive changes in principal diagnosis, whether it is clinically valid or not. We receive request to change coding based on coding rules. Coding rules, which are sometimes more complex. Like this diagnosis were based on this guideline, it's supposed to be the correct principle diagnosis instead of this one.
And present on admission indicators, but mostly it's clinical validation. Clinical validation denounce is what we get the most. Sepsis. They use a lot of the argument now that sepsis three to one that has to be used, but the facility hasn't placed the rule, the guideline that still used the sepsis two. So we have to argue that okay, although sepsis three was put into place, they don't use that. So, we have to defend it on that end. Or the patient didn't really have an increase in creatinine of more than 0.3 to be considered AKI, but the doctor wrote it consistently throughout the record. Those things are the ones we fight every day mostly. It's mostly that validation of diagnosis that they feel like the diagnosis are not clinically valid.
John: Now, when you say appeals and denials and fighting these things, I have a friend that works at a local hospital. And on the UM side, he's getting on a conference call with an administrative law judge and other people on their side and Medicare side and their people on the hospital side. Is it like that? How do you do these appeals? Who are you appealing to?
Dr. Christian Zouain: No. We received the letters directly from the auditor or the insurance company. We receive letters and the letters have their own rationale. We provide the information, we make a document and we just send it back to the hospital.
John: So, it's a written appeal.
Dr. Christian Zouain: Right. It's a written appeal. We send back to the facility. The facility is in charge. I put my signature on it with Acuity's name, and then they send it over to the corresponding auditor. But then after, we might have several levels, but after it's exhausted how we call it, that's up to the hospital to decide if they want to escalate on their own part. If they want to have a peer-to-peer with their doctor and discuss that at that point. The hospital takes care of that. We are only part of I would say three levels of written appeals. We only do it in writing.
John: Got it. Got it. Yeah. This gets all very confusing because we can throw out a term and say there's always different jobs available, but Acuity does things one way, and there's probably 10 other firms that do other things and the hospital is doing its thing. But just to give us a glimpse in the time you've been doing this, both as in the denials and even before, are these the kind of jobs that are pretty much done remotely? Does it require checking into the office and showing up in person? Is it something you can do on your own time? Is it 9:00 to 05:00? Just give us some of the constraints on these kind of positions in terms of the time and the travel and so forth.
Dr. Christian Zouain: Yeah. When we first did the first interview a few years ago, I had just started with Acuity. And at that time, I do remember that I knew when I found them, I was like, "Wow, this is amazing." Because it was actually the first company I knew that it was 100% remote, and they were hiring foreign medical graduates. Other companies would require you to have an RN license, or some sort of license to work, which I found a bit strange because I was like, really? I'm doing work from home and it's documentation. I'm not really writing a script or anything like that.
But I do believe, especially when COVID hit, when the pandemic hit, a lot of other industries they had to go into fully remote or part-time remote. Then they just basically realized that it was doable.
This work can be done 100% remote. My company Acuity, it's been 100% remote. When I started, the only thing that I had to be present for was the training, which I had to go to the main office in New York to meet with, we had to get all the access and do everything. But during the pandemic that switched. So, the training is now being done just the same way, like any other presentation that's done in the company. It's done via Zoom or Teams. It's done remotely. It's 100% remote.
Now, I do know there are probably other facilities when you have your onsite DDI program, they probably still have it. I know some of them are maybe half and half. You would go several days to the hospital so they can see you and the other days you can work from home because you have access to the electronic health record through your computer at home.
But yeah, eventually I think mostly the ones that are still in the hospital, they are still require some sort of presence. And that's good because I think that's one of the benefits of doing the onsite. I had that I would say that privilege of doing that initially when I started, which it was 100% on site, and the hospital I used to work for was hybrid. They still had part of the records in paper charts.
So, it wasn't something that we could even argue like, "Hey, listen, can we do one day from home?" No, that was out of the question because they were still on paper and we had to go to the floor. But that helps you a lot to build that, to break out of that shell, I would say, to get close to the physicians, have a conversation, get to understand what's really going on with the patient, get their view. And also they learn from you in terms of, "Hey, listen, this is why I'm asking you because this documentation translates into this." Now with being 100% remote, you can't do that. After I started working with Acuity, my contact, when I was writing queries, I would talk to a doctor maybe once every two months. And it was because they would call me, they would see my name on the query, but they weren't really supposed to. They were someone else in a different department who would take care of that. Whereas when I was in the hospital, it was constantly, for every single query I sent, I had to talk to the physicians.
John: Yeah. Interesting. It has evolved quite a bit. I was talking to someone who does UM. He is relatively new, but it was kind of the same thing. He's in a system and they didn't really have a pretty robust UM program. He was assigned and he took a job as a medical director, and there were multiple sites, but he was doing half of it remote because he couldn't drive hundred miles in a day to hit every hospital. He'd do some of it remote, and then sometimes he had to show up and meet the physicians, and he really thought that helped. But I could see him migrating at some point to a 100% remote job with a big company because the lifestyle is so much better.
And so, would you say in general that most physicians are going to be very happy with working in CDI at one of these companies in terms of the lifestyle, the pay and vacation and opportunities for advancement?
Dr. Christian Zouain: Yeah, absolutely. Absolutely. The shift that I've seen and the opportunities just like I've seen in my own work environment, even though I don't interact as much. The company right now from the last town hall, they said we had about 600 employees nationwide. They did implement some sort of activity that we would do. Everyone that lives in the same state or close by, like in the same city, they would get together. I was able to meet a few of the doctors that work for the company as well and other coders. One of them was head of IT education portion of Acuity.
The others, they were directors of coding. There's a lot of opportunities still out there. I think much more that than what I know of, but definitely, again, just like I said, knowing the craft can get you towards getting a lot of opportunities in the field. And I've seen that. I would continue to encourage everyone that likes it and finds the value in it. It's really a good career. And all the companies, just like the one I work for, they're doing a great job and they're growing, expanding, and they're doing a lot of great things.
John: Excellent. That's good to hear. We want to have as many opportunities for our physicians as possible as they decide to transition to something maybe out of clinical that they're doing now or something like that.
We are going to run out of time. We're probably getting close to the end here. Real quickly, if someone is currently in practice, maybe they're doing some inpatient so they have exposure to that part of it, what would you advise them is how to start to look at making that transition? They just start looking up jobs, or is there something they can do in the meantime to set them up to succeed if they decide to apply for a job like this with one of the companies that does the remote CDI activities?
Dr. Christian Zouain: Yeah, I would say it would be the same advice I gave on the first part podcast. Again, you basically have the clinical knowledge part. Just get into knowing more about the coding aspect, how it works. Maybe do a coding course geared toward maybe a certification like a CCS. That's one I would say. For example, there's several coding certifications, but the CCS, it's like the more expert one. But for us physicians, to be honest, it's something that it's not that hard to acquire because we already handle all the terms, all the clinical terms. We just have to know all the coding rules and games, again, like we mentioned earlier.
After that, again, I know that Acuity has that particularly that the medical director position, the doctors they hire, they do have some coding, clinical background, but they don't need to be really like coding experts per se because they're looking more toward the clinical part and having a basic understanding of the coding part. And along with the coding director and with the company itself, you're going to be able to start learning everything and grasping. Because again, every company does everything on their own way.
There's not a specific way. Just like every hospital, CDI program does things a certain way. I know this because since I've worked for different facilities, one might think, "Oh, well, maybe when I go to this next job or this next facility, they might think I don't know how to do it because we did it differently."No, everyone in the industry is very aware that every facility has their own ways of doing things, but the core of everything is knowing the basics of medical coding and how it works. Other than that, it's just a matter of time and experience. Even till this day, I don't know everything, I don't think I'll ever know everything because again, there's a lot out there and everything changes from time to time, but it's a constant process.
There are certain things that are the main focus. There's always opportunities for sepsis, for acute kidney injury. There's diagnoses that are pretty common, for example. There's commonalities on every industry. But that would be my advice. Getting to coding and reach out to other colleagues that are doing the same thing, either in your hospital or through LinkedIn.
Right now, I do remember someone that reached out to me. I think it was who listened to your podcast about a year ago. I do remember she told me. I'm glad she listened to the episode. And a year later she messaged me again, and she told me, I just wanted to let you know that I was just hired in your company. And I didn't know. She actually went on her way. I think she got a coding certification, and she met someone else from the company through LinkedIn. And I think they established a friendship. And she was able to get hired for her first job in CDI 100% remote, which was something that if you would've asked me, probably like five years ago, I would've said no. You have to start maybe on a hospital, that they give you an opportunity on onsite. But now, it's possible. There's a lot of opportunity out there. There's a lot of facilities. You can reach to a lot of people.
John: Plus the power of networking.
Dr. Christian Zouain: Yeah.
John: It's like meeting people, getting advice, getting mentors and talking about their company. Who do I apply to? Is there someone I can talk to? There's so many little tricks you can do too along the way.
First I want to say that you're on LinkedIn, obviously, as you mentioned. Just look Christian Zouain up, or if you want to use the URL, I think it's linkedin.com/in/christianzouain. It's hard to miss you really. There aren't that many other Christian Zouains around. I don't think. I do see though on your LinkedIn frequently you'll post that your company has openings. I could put you on the spot now and say, are there openings there? And if someone has a question about an opening, they can just go ahead and apply, but I suppose it'd be okay to contact you and ask you a little bit more about it.
Dr. Christian Zouain: Yeah, definitely, if anyone is interested. As soon as I see any posts from HR or anything, I would do a repost just so anyone can see. If anyone has any questions, again, just like you mentioned earlier, I want to emphasize just like we did. I know we did on the first podcast interview, like networking that is very important, not just for this industry, for anything that anyone would want to do or pursue. The power of networking, it's very powerful. I would say reach out. Don't be afraid to reach out to anyone for advice. If you don't get a response from someone just move to the next one. There's a bunch of people. Look for someone that works in the company you want to work for and try to establish a connection with them. But if you see me reposting or you can go to Acuity's website, acuityhealthcare.com, or follow them on LinkedIn, they usually post the open positions there. If you have any questions on that, you can reach out to me. Just to throw it in there, we have a referral program. If you want to mention my name, just to put it out there, you can also do so.
But yeah, I'm available for any questions that you might have, any orientation that I can provide. By doing this, what I'm trying to do is be the person that I wish I could have found when I first started, because there was not a lot of people out there. Yesterday I spoke to, there was someone that came to my house. He's a nurse. He works as a nurse in the hospital, but then he's a doctor back in Brazil. And he was telling me. He came in, he did the process of getting his RN license and all of that. I was telling him what I did, and he was impressed because he said, "You know what? I've been doing this. I've been working here 15 years and I've never heard of what you do." And I said, "Really?" And he was like, yeah.
We talked for a while and I said write down my phone number. I send him the presentation I've had that I did back to do the Medical Association to that group of doctors. Because still, sometimes I'm impressed by the fact that these opportunities are really not out there so people can see them. Even if they're in the hospital, if they don't find the right person, some people maybe they keep more to themselves and all that, but whenever I find a colleague and they tell me they're a foreign doctor or a doctor that is trying to do residency, I tell them what I do, because you never know. And also I'm always open to give advice or even not just give advice, also learn, because I can learn from the other person as well.
John: I know there's at least a thousand physicians and other clinicians who eventually will listen to this episode. And so, I'm going to tell you that if you have any linkage whatsoever with a hospital or with documentation, coding, patient care, and if you're actually practicing, of course, you're exposed every day, then this is an opportunity. There's a huge need. It's a good lifestyle, and you're applying your medical background. And so, what could be better?
And the other thing is I don't apologize about maybe having someone mention that you referred them to your employer, because guess what people? I'm talking to my listeners now. All my guests come on for free. They take their time, they share because they're professionals or physicians, most of them, and they want other physicians to prosper and succeed and be happy in their careers, not be miserable doing corporate style healthcare seeing 50 patients a day and working all weekend. The least you can do is if you contact Acuity that you mentioned Dr. Zouain's name just as a little bit of a bonus for taking the time to share his information with us. So I do appreciate that, Christian.
Dr. Christian Zouain: No, thank you. Thank you for allowing me to be on your platform.
John: Basically Christian is agreeing to be your informal mentor. And by the way, if you need a mentor in the future, I always remind my listeners too. A mentor is not someone you're going to sit down for three hours with and take up all their time. A mentor is someone you just go to, you send them a note, or you have a brief conversation, ask them a question, and boom, you just take their advice and move on. And then maybe reconnect again three or six months later. We're not talking about intense coaching here. We're talking about just networking and communicating and getting a little bit of free advice.
Dr. Christian Zouain: Absolutely.
John: All right, Christian. I guess it's time to go. I really appreciate you being here today. It's been fun. I've enjoyed catching up and learning from you, again, more about CDI since I was involved with it over 10 years ago. I'm sure we can reconnect again down the road. Again, thanks for being here today.
Dr. Christian Zouain: Definitely. Thanks a lot, Dr. Jurica.
John: All right. With that, I will say goodbye.
Dr. Christian Zouain: All right. Take care. Bye.
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The opinions expressed here are mine and my guest’s. While the information provided on the podcast is true and accurate to the best of my knowledge, there is no express or implied guarantee that using the methods discussed here will lead to success in your career, life, or business.
The information presented on this blog and related podcast is for entertainment and/or informational purposes only. I do not provide medical, legal, tax, or emotional advice. If you take action on the information provided on the blog or podcast, it is at your own risk. Always consult an attorney, accountant, career counselor, or other professional before making any major decisions about your career.
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