The Ketamine StartUp Podcast

Dr. Zach Fisk runs a pain medicine practice. That is how he would describe it, and that framing matters. Acute Pain Therapies in Bellevue, Washington offers a genuinely broad range of interventions including stellate ganglion blocks, regenerative medicine, peripheral nerve stimulation, spinal cord stimulators, PRP, and radiofrequency ablation. Ketamine sits within that model as one of many tools, not the headline, but arguably the one that changes lives most dramatically when it is the right fit for the right patient.This conversation gets into how that practice was built, what drives the clinical decisions behind it, and what it actually takes to sustain something like this over nearly a decade.Dr. Fisk is a board-certified anesthesiologist with fellowship training in acute pain management and an MBA from Tufts. He opened Acute and Chronic Pain Therapies in Bellevue, Washington in 2016 after leaving a stable position at the VA, where the chief of anesthesia told him his idea for an outpatient perioperative pain service was dead in the water. Eight years later, he is still going.This conversation is wide-ranging and genuinely honest. Dr. Fisk talks about his dosing philosophy and why he does not find body weight to be the most useful guide, his experience billing insurance for ketamine and why he eventually went fully cash pay, the role of outpatient sublingual ketamine in his practice, and how he thinks about patient selection after nearly a decade of doing this work. He also shares what he would tell an anesthesiologist or pain physician who is considering opening their own clinic, and it is not the answer most people expect.What You'll Gain:• How Dr. Fisk built one of the most comprehensive multimodal pain and ketamine practices in the Pacific Northwest, and why he believes ketamine works best as part of a broader clinical model rather than a standalone offering•  His honest account of the early days, including seeing two patients in his first month, the VA chief who called his idea dead in the water, and what kept him going through the uncertain early period• A detailed look at his dosing philosophy for ketamine infusions, including why he does not rely primarily on body weight, how he structures dose titration over one hour, and how he tailors protocols to individual patient profiles• The insurance journey that started with unexpected coverage, moved through clawbacks and audits, and ultimately led him to go fully cash pay, including his candid take on why insurance covers Spravato but not IV ketamine• How he thinks about outpatient sublingual ketamine prescribing, when he uses it, when he does not, and why he draws a boundary around prescribing it purely for psychiatric indications given his anesthesiology background• His straightforward advice for anesthesiologists and pain physicians considering opening their own clinic, including why he says this path is not for most people and what you genuinely need to be prepared forEpisode 67 show notes:00:00:00 Teaser: Risk, Stability, and Building Something of Your Own00:00:17 Welcome and Meet Dr. Zach Fisk00:01:43 Dr. Fisk’s Path: Tufts, Anesthesia, and Acute Pain Fellowship00:02:35 The Idea for an Outpatient Perioperative Pain Clinic00:03:56 Why Ketamine Became a Primary Service, Not a Background One00:06:19 The MD/MBA Path and How Business Training Shaped the Practice00:09:18 From Fellowship to the VA: Building an Acute Pain Service00:10:21 Leaving a Stable Job When You Want to Build Something00:11:31 “We’ve Never Been Trained in Business, So I Just Went for It”00:13:21 Year One Reality: Two Patients in the First Month00:14:00 Early Hiring Mistakes and Why a Startup Consultant Made the Difference00:15:32 What Medical Training Never Teaches: HR, Finance, and Practical Skills00:20:00 The VA Chief Who Called It “Dead in the Water”00:22:08 The 80-Year-Old Test: Taking Risks While You Still Can00:26:00 Inpatient vs. Outpatient Ketamine: Dosing, Duration, and Monitoring00:31:34 One-Hour Infusions and a Two-Titration Protocol00:33:05 Why Body Weight Is Not the Best Guide to Dosing00:36:50 Building a Multimodal Practice: Services Beyond Ketamine and SGB00:41:47 Patient Stories: When Ketamine Changes and Saves Lives00:43:10 Red Flags, Patient Selection, and Honest Conversations About Success Rates00:44:40 Outpatient Sublingual Ketamine and the Lucinda Grande Protocol00:47:52 The Insurance Journey: From Clawbacks to Cash Pay00:51:40 The Spravato vs. IV Ketamine Insurance Mystery00:55:03 Advice for Anesthesiologists Considering Private Practice00:57:31 Rapid-Fire Questions Begin01:02:42 Where to Find Dr. Fisk and a Tip on Naming Your Business01:04:33 Episode EndingThanks for listeningConnect with Dr. Fisk at:Acute Pain Therapies Website https://acutepaintherapies.com/Instagram https://www.instagram.com/acutepaintherapies/📝 Complete show notes with resources and  links, please visit https://www.ketaminestartup.com/podcast/episode-067Follow us onLinkedinKetamine StartUp WebsiteYouTube🚀Want to fast track launching your ketamine clinic? If so, download our free checklist.

This week we are reaching back to our very first season to resurface a conversation that has stayed with us. And there is a reason we keep coming back to it.There are a lot of conversations about the mechanics of opening a ketamine clinic. This one is about the why behind it.Dr. Glareh Imani is a board-certified emergency physician who opened Nameen Infusion and Wellness in Goodyear, Arizona after more than eight years in emergency medicine. Her background in neuroscience, her personal experience with ketamine, and a deep sense of gratitude shaped the kind of clinic she built and the way she shows up for her patients every day.What makes this conversation stand out is how honest and human it is. Dr. Imani talks about the unexpected challenges of opening a clinic, the patient transformations that confirmed she had made the right choice, and the personal evolution that came with doing this work. She also reflects on autonomy, on what it means to finally be the one making the decisions, from clinical protocols to the waterfall in her reception area.Recorded at the ASKP3 conference in Austin, Texas during our first season, this episode holds up beautifully. If you are considering the pivot from your current position, or if you are early in building your practice and need a reminder of why you started, this one is for you.What You'll Gain:· Dr. Imani's honest account of what it took to go from the idea of opening a ketamine clinic to actually delivering on it, including what surprised her most along the way· How her background in neuroscience and her personal experience with ketamine shaped both her decision to open a clinic and her approach to patient care· What set and setting actually means in the outpatient clinic context, and how Dr. Imani thinks about the environment she has created for her patients· Two patient stories that capture what ketamine therapy can do when it is delivered with intention and individualized care· What the transition from corporate emergency medicine to clinic ownership actually feels like, including the autonomy, the trade-offs, and the parts you cannot put a price on· How Dr. Imani balances running a clinic, working emergency medicine shifts, and family life, including what she says makes it all possibleEpisode 66 show notes:00:00:00 Teaser: "I'm Happier Now Because I Know I Can Help in a Different Way"00:00:18 Episode Introduction00:02:03 Background: From Neuroscience to Emergency Medicine to Ketamine Therapy00:06:13 Her Personal Ketamine Experience and the Decision to Open a Clinic00:08:19 Unexpected Challenges and the Backup for Everything Rule00:09:00 Ketamine in the Hospital vs. the Outpatient Clinic: Set and Setting00:10:33 Safety Standards and Why EM Training Is an Advantage00:13:00 Patient-Centered Care, Setting Expectations, and the Tools She Relies On00:15:08 Advice to Her Past Self: Start Sooner and Do Not Do It for the Money00:18:02 The Power of Autonomy and What Clinic Ownership Actually Feels Like00:19:40 Personal Evolution: Mindfulness, Journaling, and Resetting Yourself First00:23:21 Patient Stories: Transformation That Confirms the Decision00:26:24 Balancing a Clinic, ER Shifts, Family Life, and Why Community Matters00:28:40 Rapid-Fire Questions Begin00:37:00 Time Travel: Being a Teenager in Vienna as a Refugee00:38:22 Gratitude, Resilience, and the Gift of Helping Others00:40:10 Final Thoughts and Where to Find Dr. Imani00:40:54 Episode EndingConnect with Dr. Imani at:Nameen Infusion & Wellness websiteNameen Infusion & Wellness Instagram📝 Complete show notes with resources and  links, please visit www.ketaminestartup.com/podcast

This Soundbite from the Vault packs three genuinely useful sections into one digestible clip, and each one stands on its own.It opens with something most emergency medicine physicians quietly wonder about before making the pivot: what does it actually feel like to work in a ketamine clinic after years of shift work? Dr. Nico Grundmann, founder of Ember Health in New York and an emergency physician with an MBA from Stanford, gives a refreshingly honest answer. The schedule changes. The mental model changes. The relationships you build with patients are unlike anything the ER allows. And for the right person, all of that is exactly the point.The middle section pulls back the curtain on what patient care can actually look like. From the first call to the four-visit induction series to long-term maintenance care, Dr. Grundmann walks through the full patient journey at Ember, including their 84 percent real-world treatment response rate and why they believe the care coordination model is what drives it.It closes with the three things Dr. Grundmann would tell anyone opening their own ketamine practice. Not generic advice. Specific, hard-won pillars that have shaped how Ember operates across five New York City locations and more than 2,200 patients treated.What You'll Gain:· An honest account of what actually changes when you move from emergency medicine to a ketamine clinic, including the parts most people do not talk about before making the leap· Why care coordination takes up 30 to 40 percent of the day at Ember and what that means for EM physicians who are used to handing off at the end of a shift · A clear picture of what the patient journey looks like inside a well-run ketamine practice, from first consultation through long-term maintenance care · Why Ember's real-world treatment response rate of 84 percent outperforms the published academic data of 75 percent and what Dr. Grundmann believes is driving that difference · The three pillars Dr. Grundmann would share with any provider opening their own ketamine clinic, built from years of operational experience across multiple sitesEpisode 65 show notes:00:00:00 Teaser: "This isn't a role where you clock out and you're done."00:00:13 Episode Introduction 00:01:25 What Is It Actually Like to Work in a Ketamine Clinic After Years of Shift Work?00:03:20 Who Is a Good Fit: Longitudinal Care, Fixed Schedule, and Panel Management00:05:00 For the Right Person It Checks Every Box: What the Fulfilling Version of This Work Looks Like00:07:58 What Does the Patient Journey Actually Look Like from First Call to Treatment?00:10:30 Real-World Treatment Response Data: 84 Percent at Ember vs. 75 Percent in Published Literature00:12:33 Three Pieces of Advice for Anyone Opening Their Own Ketamine Clinic00:14:36 Episode Ending Thanks for listeningSelected Links From the Episode:Want to go deeper? This soundbite comes from Episode 040 – Episode 40 - Scaling Ketamine Clinics: From Pilot to Five Locations with Dr. Nico Grundmann, where we cover the full conversation including how Nico built Ember from a one-room pilot site to five locations in New York City and the systems thinking behind all of it.Follow us onLinkedinKetamine StartUp WebsiteYouTube🚀Want to fast track launching your ketamine clinic? If so, download our free checklist.

Clinical Disclaimer: This episode is for educational purposes for licensed healthcare professionals and is not individual medical advice. Ketamine and esketamine are not FDA‑approved for preventing or treating postpartum depression; any use in this population is off‑label and should be considered investigational and undertaken only with appropriate training, collaboration, and adherence to current standards of care.Postpartum depression affects roughly 10 to 20 percent of mothers and remains one of the most undertreated conditions in medicine. As public awareness of maternal mental health grows, providers in the ketamine and psychedelic therapy space are increasingly asking: is there a role for ketamine or esketamine here?This episode is our evidence-based answer to that question.We walk through the current clinical literature on ketamine and esketamine for perinatal depression, drawing on randomized controlled trials, meta-analyses, and expert commentary from institutions including the Center for Women's Mental Health at Massachusetts General Hospital. The research landscape is more nuanced than most providers realize, and understanding it clearly matters both for patient conversations and for how you think about your practice's scope.One distinction shapes everything that follows in this episode, and it's an important one: virtually all of the existing trial data involves perioperative prevention in cesarean delivery populations, not outpatient treatment of established postpartum depression. Knowing what the evidence actually supports and where the gaps remain is essential context for any provider working in this space.What You’ll Gain· A clear breakdown of what current ketamine and esketamine trials actually show for postpartum depression prevention, and what limited data exist for treatment.· An understanding of why racemic ketamine and esketamine tell different stories in the peripartum literature.· The key ethical and practical considerations for any provider thinking about this population.· An honest framework for how to talk with patients who ask about ketamine for postpartum depression.· Context on what the research gaps mean for where this field is heading.Review the research behind this episode, including full citations for every study discussed, in the Clinical References and Further Reading.📖 Prefer to read? We turned this episode into a full blog post with structured tables comparing the racemic ketamine and esketamine evidence side by side, plus a research gaps summary you can reference and share with your team: Read the Blog PostEpisode 64 show notes:00:00:06 Episode Introduction00:02:02 Clinical Context: Defining PPD, Postpartum Psychosis, and Perinatal Depression00:03:34 Prevalence, Public Health Burden, and Why Cesarean Delivery Matters Here00:04:40 Why Ketamine and Esketamine Are Conceptually Interesting in This Population00:05:38 Prevention vs. Treatment: A Critical Framing Point Before the Research00:06:32 Racemic Ketamine in the Peripartum Setting: Mixed and Conflicting Signals00:09:22 What the Meta-Analyses Tell Us: Darwish et al. 2025 and Li et al. 202400:11:18 Bottom Line on Racemic Ketamine in the Peripartum Setting00:12:05 Esketamine: Why It May Outperform Racemic and Why This Is Not About Spravato00:13:32 The Esketamine Trials: From Early Signals to the 2024 BMJ Landmark Study00:18:51 Treatment vs. Prevention: What About Established PPD?00:21:29 Ethical and Practical Considerations00:21:40 Lactation and Infant Exposure00:22:14 Neurodevelopment Data: The Long-Term Unknown00:22:35 Informed Consent in the Peripartum Period00:23:04 The Tension Between Rapid Relief and Premature Clinical Adoption00:24:10 Clinical Takeaways, Research Gaps, and What Cautious Optimism Looks Like in Practice00:24:27 What the Evidence Supports: Esketamine Summary00:25:23 What the Evidence Does Not Yet Support: Outpatient PPD Use00:25:41 Bottom Line on Racemic Ketamine: Summary00:26:07 Five Research Gaps the Field Needs to Address00:27:56 What This Data Means for Ketamine Therapy Providers Right Now00:30:03 Closing Remarks Thanks for Listening📝 For Complete show notes along with the the research behind this episode, including full citations for every study discussed, please visit http://www.ketaminestartup.com/podcast/episode-064

In this episode from the vault, we’re going back to when Sam gave a presentation at the American College of Emergency Physicians (ACEP) Scientific Assembly, making the case for why emergency physicians and clinicians are uniquely positioned to successfully practice in the ketamine therapy space.This is not a generic overview of ketamine. It is a frank, evidence-based conversation directed at clinicians who are feeling the weight of burnout, decreased autonomy, and a healthcare system that is asking more while giving less in return. Sam walks through the science, the mechanism, the financial realities, and the deeper question of purpose that every provider should sit with before taking the leap.If you have ever wondered whether your emergency medicine training could translate into something more fulfilling, this episode makes a compelling and well-researched argument that it can.What You'll Gain:• A clear picture of the mental health and chronic pain crisis driving demand for ketamine therapy, and why the current standard of care is falling short for so many patients• A walk through the key clinical studies supporting IV ketamine for depression, anxiety, PTSD, and chronic pain, including the landmark 2023 New England Journal of Medicine trial comparing ketamine to ECT• An honest look at the mechanism of action behind ketamine therapy, from NMDA receptor antagonism to neuroplasticity and BDNF, explained in language that makes clinical sense• Why emergency physicians bring a uniquely transferable skill set to the ketamine therapy space, and how that advantage plays out in practice• The financial and emotional realities of running a ketamine clinic, including what Sam wishes more providers understood before they opened their doors• Why knowing your why is the single most important thing you can do before starting a ketamine practice, and how it will carry you through the inevitable hard momentsEpisode 63 show notes:00:00:00 Teaser: "This is the why, the purpose, the motivation."00:00:34 Episode Introduction and Overview00:01:45 The Mental Health Crisis: Why This Work Matters Now00:03:48 Burnout and the Changing Landscape of Emergency Medicine00:04:43 Why EM Physicians Are Uniquely Positioned for Ketamine Therapy00:05:02 The Clinical Evidence for Depression: From the Berman 2000 Study to the 2023 NEJM Trial00:07:25 The Clinical Evidence for Anxiety: Dr. Paul Glue's Escalating Dose Study00:08:20 The Clinical Evidence for PTSD: Single and Multiple Infusion Data00:09:41 The Clinical Evidence for Chronic Pain: What Works and What Doesn't00:10:55 Mid-Episode Ad: Free Ketamine Startup Checklist00:11:44 How Ketamine Works: NMDA Receptor Antagonism and Glutamate00:12:19 Multi-Receptor Action, Neuroplasticity, and BDNF00:13:30 Beyond the Mechanism: The Experiential Dimension of Ketamine00:14:40 The EM Skill Set Advantage: Clinical Experience, Procedures, and Scheduling Flexibility00:15:24 Emergency Medicine Is a Mindset, Not a Location00:15:53 Before the How, There Is the Why00:16:39 The Toxic Waste Pool: A Story About Purpose and Motivation00:17:23 The Financial Reality: Don't Open a Clinic for the Money00:18:14 Why You Should Open a Ketamine Clinic: Purpose, Autonomy, and Saving Lives00:18:55 Patient Testimonials: In Their Own Words00:20:17 OutroThanks for listening🎥 Prefer to watch? This episode was originally a live conference presentation with slides covering the clinical studies, mechanisms of action, and other helpful visuals. The YouTube version brings all of that to life: Watch Episode 063 on YouTube📖 More of a reader? We turned this presentation into a full blog post covering the clinical evidence, why your EM training is an unfair advantage, the financial reality nobody talks about enough, and what patients say when the treatment works: Read the Blog Post📝 Complete show notes with resources and  links, please visit https://www.ketaminestartup.com/podcast/episode-063Follow us onLinkedinKetamine StartUp WebsiteYouTube🚀Want to fast track launching your ketamine clinic? If so, download our free checklist.