[Editor's Note: Today's guest post was submitted by Dr. Samuel Ko, the founder and medical director of Reset Ketamine in Palm Springs. Every start-up business will need to be ready to handle curveballs thrown their way. Dr. Ko is a good example of the entrepreneurial spirit necessary to find ways to thrive when the unexpected thwarts their path. We have no financial relationship.]
In the past decade, I’ve worked as a community emergency physician, an associate medical director in the emergency department (ED), and an assistant professor of emergency medicine (EM). I love making and executing decisions, seeing rapid improvements in patients, and taking time to connect with patients. But over the years, I’ve slowly realized the ladder that I was climbing was placed upon the wrong building. That is, until the seed of a ketamine clinic startup was planted in my neurons.
Two roads diverged in a wood and I – I took the one less traveled by, and that has made all the difference. – Robert Frost
As you may know already, ketamine is being used off-label for the treatment of depression, PTSD, anxiety, OCD, and some types of chronic pain. Scientists have called ketamine “the biggest breakthrough in depression research” in 50 years.
After two years of false starts, analysis paralysis, and discussion with friends and family, I opened up Reset Ketamine, the first clinic of its kind in Palm Springs, CA in 2018.
I won’t kid you, it was tough. Not physically, but rather overcoming my own internal mental barriers as well as logistic obstacles. No one is taught how to open up your own clinic in medical school and certainly not in EM residency.
One of my mentors, an emergency physician who had started an ambulance and event medicine company told me, “Sam, perfection is the enemy of execution. Strive for excellence instead.”
He could see that my ideal to do it “perfectly” was limiting me from actually starting up the clinic.
Finding the Clinic Space: From Perfection to Get the Job Done
I started looking for medical offices. Most were too expensive, too big, too small, or too old. Nothing really fit exactly what I was looking for. I even contacted other doctors to see if I could rent out an extra spare room, but didn’t get any responses. I figured I’d just push back the opening date while looking around for the perfect office space.
With some encouragement from my wife and partner, I decided to look in another city for the office instead. This would require a 45-minute commute, but once I started looking in Palm Springs, a location opened up immediately. It wasn’t perfect, but it would definitely get the job done.
After some negotiation, I signed the lease and took a step on my path.
Getting Malpractice Insurance Coverage: Be Persistent
I began looking for malpractice insurance coverage for ketamine infusions. I applied with an insurance broker. He came back to me and said that out of the six companies he contacted none would cover IV ketamine infusions.
I was devastated. How could I open up without medical malpractice coverage?
I directly called up one of the companies who initially denied my application and asked to speak with someone about my situation. After a long discussion with the senior underwriter for 90 minutes about off-label IV ketamine use, she said she’d bring it up to the committee and let me know.
I got an email from her a few days later. I was APPROVED for malpractice coverage! It would cost a lot, but still it was a hurdle that I’d overcome towards my goal.
The Buildout: Digging Deep
At a minimum, all I needed was a waiting room, a sink, a bathroom, and one room for the infusion space. My contractor was working on the clinic and the costs were quickly adding up—much more than I had planned for. I was feeling overwhelmed and stressed about the added costs. What if I invested all this money to open up the clinic and no one showed up?
But I knew that I would regret it if I stopped now. Accordingly, I dipped into our personal emergency funds and transferred money into the business account to cover the extra costs.
A Ketamine Shortage: Leveraging My Contacts
Soon everything was coming along nicely. The office was nearly finished and I had figured out the various licenses, supplies, etc. that I would need, except the most important part.
As I tried to order ketamine, I learned that there was a nationwide ketamine shortage. I kept waiting for the backordered ketamine to come through, but to no avail. It was one week before the planned opening date, and yet I had no ketamine at a ketamine clinic.
I scrolled through my contacts and reached out to my network. I recalled a colleague who was previously an ED pharmacist and had recently opened up an outpatient pharmacy. After a few calls, he was miraculously able to find a wholesaler and order several boxes for me.
Whew. Ketamine secured!
Placing IVs: Practice Makes Perfect
In the ED, I rarely put in the peripheral IVs since that is typically done by nursing staff. I wasn’t sure a nurse would want to work at a clinic that was open by appointment only (irregular hours) and had only a few infusions the first month.
So I reached out to an old friend, who was a nurse at an ER I used to work at. She was now a nursing director of an urgent care. Generously, she volunteered her time and said she’d work for me for free for a few hours on her days off.
And that’s how the first infusion happened. A last-minute ketamine order, a volunteer ER nurse, and me in our small, newly renovated office.
Some days, my RN friend couldn’t come so I had to start my own IVs. I purchased a vein finder and practiced a lot. But for one patient, I had to poke him 5 times before getting a line.
Eventually, the Butterfly Ultrasound became available so now I can easily get a peripheral IV in any patient.
Keeping a Low Overhead: Minimizing Pressure
The first month of opening I saw less than 4 patients. Fortunately, I kept my overhead low. I did the majority of the work, hired my sister-in-law for front office work, and continued working in the ED to help with financial stability.
As the volume of patients began trickling upward, I gradually reduced the number of ED shifts each month. Because I kept my overhead very low, I never felt pressure to see difficult patients or try any type of “hard sell” to get more patients.
Marketing: Direct to Patient vs. Referral Dependent
I sent a letter to all the local primary MDs and psychiatrists announcing that I was opening up a ketamine clinic. Unfortunately, there weren’t many referrals. But through our blog, YouTube channel, and social media (Twitter, Instagram, LinkedIn), patients began finding our clinic on their own.
With the help of my partner and wife, we continued making lots of informational videos, blog posts, and I gave presentations to share the science behind the off-label use of IV ketamine.
Initially, the audience was small, but with continued efforts, we now get more visitors to our website in a week than what we got in the first few months of opening.
COVID-19 Pandemic: From Side-Hustle to Main-Hustle
COVID-19 came crashing down on us which caused a dramatic drop in the number of patients both at the ketamine clinic and in the ED. Since I was a part-time ER doctor, I wouldn’t be given any shifts in the ED for several months so that the full-time emergency physicians could get their allotted hours. All of a sudden, the most stable job in the world became unstable.
Fortunately, I was able to access the PPP Loan and obtain an SBA grant. Also, there were still a number of patients coming in for ketamine booster treatments at the clinic.
On top of this, there was a national Personal Protective Equipment (PPE) shortage, and I couldn’t buy any surgical masks, gloves, or face shields. Luckily, the California Medical Association had an opportunity for a small doctor’s office to receive free PPE right in the nick of time.
Redefining Myself: From ER Doc to Ketamine Specialist
With the pandemic and a shift in my perspective, I’ve decided to take a sabbatical from the ER. I’m not sure how long it will be, but I believe I’ve found my niche in medicine. Furthermore, my autonomy in medicine is higher than ever, my patients get rapid improvements, and I have the time to connect with my patients.
In the past, patients in the ED would ask me, “What are you going to specialize in after your time in the ER?” Now, I can confidently answer, “I am a ketamine specialist.” I was trained as an emergency physician and never thought I’d end up owning a private practice ketamine infusion clinic. But it’s been one of the best decisions I’ve made and I'm able to utilize my unique skill set to transform patients' lives.
I’ve had many physicians reach out to me and ask how I started up a ketamine clinic. So I’m working on an online course. The goal is to help other physicians go from feeling lost and overwhelmed to feeling empowered and knowledgeable to start their own ketamine clinic in under 12 weeks. On the site, there’s also a link to download a free ketamine clinic start-up checklist. If you have any questions, feel free to reach out to me.
What advice do you have for a new practice owner for handling the unexpected? How did you overcome analysis paralysis when deciding to start a business? Comment below!
Interesting. I went through starting a practice myself. I never planned to do it. I ended up starting an OB/GYN practice after moving back to my hometown after the original local practice imploded. I think the most important early decision a practice owner makes is the office. In most cases people simply pay way too much for their office and are dogged by overhead their entire careers.
Do third party payers pay? Will you accept recreational Ketamine users? Won’t you need a strong psychiatry background? Interesting post.
Hi David,
Thanks for reading the post and commenting! To answer your questions:
There is a slow and gradual trend of insurance companies covering ketamine infusions for mental health and pain conditions (e.g CRPS/RSD). For example, Massachusetts Blue Cross/Blue Shield is now covering IV ketamine treatments :
https://www.bluecrossma.org/medical-policies/sites/g/files/csphws2091/files/acquiadam-assets/087%20Esketamine%20Nasal%20Spray%20%28Spravato%29%20and%20Intravenous%20Ketamine%20for%20Treatment%20Resistant%20Depression%20prn.pdf
I don’t accept recreational ketamine users and screen all the patients very carefully prior to any treatments. I also review the patient’s medical records prior to beginning treatments.
I aim to collaborate with the patient’s psychiatrists/therapist and want my patients to continue seeing them regularly. At the clinic, I am not making psychiatric diagnoses nor trying to become a patient’s psychiatrist.
Rather, my goal is to provide outpatient ketamine infusions within a safe, monitored setting (HR, BP, O2 sat, RR, etc) with equipment & meds necessary to handle any emergencies that can come up.
The two medical specialties that are most familiar with intravenous ketamine administration is ER and anesthesiology.
Sam
Hi Hatton,
Thanks for posting.
You’re totally right, having an expensive office space can be a HUGE burden, especially when first starting out.
Sam
Longtime reader. I think this deserves a lot of scrutiny before this is promoted. Ketamine has a high propensity for abuse and addiction (activates opioid receptors). Although it is promising from an inpatient perspective, the author’s website promotes it for chronic pain and fibromyalgia. Is it really a good idea to cash in on the public’s trust with entrepreneurial clinics if there is a chance that is leaves a wave of addicted patients in its wake? Obviously not. Let’s not make our day jobs that much harder.
Hi John Galt,
Thanks for taking your time to read my article. Wanted to respond to some of your questions/comments:
THE RESEARCH
Ketamine is the most commonly used medication in the world for sedation/pain control and is listed on the World Health Organization’s List of Essential Medications.
It’s been over 20 years since the first double-blinded, placebo-controlled trial published by Dr. Berman et al, from Yale University, which showed a significant drop in depression vs. placebo. “Antidepressant effects of ketamine in depressed patients.” https://pubmed.ncbi.nlm.nih.gov/10686270/
This initial study was a very small sample size because it was a pilot study. However, since then many more studies have been done. There are now meta-analysis and systematic reviews confirming that ketamine infusions can be helpful in treatment-resistant depression.
“A systematic review and meta-analysis of the efficacy of intravenous ketamine infusion for treatment resistant depression: January 2009 – January 2019.” Journal of Affective Disorders Volume 277, 1 December 2020, Pages 831-841. https://www.sciencedirect.com/science/article/abs/pii/S0165032720327026
Furthermore, a study published in 2018 in the Journal of Clinical Psychiatry, “Acute and Longer-Term Outcomes Using Ketamine as a Clinical Treatment at the Yale Psychiatric Hospital,” found no evidence of long term adverse effects in their study population. See: https://pubmed.ncbi.nlm.nih.gov/30063304/
ADDICTION:
We haven’t seen any addiction-like behaviour in our patients at my clinic.
Ketamine predominantly works by blocking glutamate activity on the NMDA receptor, NOT the opioid receptor, although there may be some interference with the opioid receptor.
“These NMDA receptors are found together with the opioid receptors on brain cells, and Kaplin says it’s no surprise that their components can meddle with one another, like interference picked up on a phone call or on the radio. “This interference and cross-talk does not mean that ketamine is an opioid, and to wrongly label it as such could eventually keep patients from essential antidepressant medications that could make a huge difference in their quality of life.” ~Dr. Adam Kaplin
See: https://hub.jhu.edu/2019/08/02/ketamine-not-an-opioid/
Although ketamine has a risk of addiction and abuse, it is considered to have a “LOW DEPENDENCE POTENTIAL.” Even lower than opioids, alcohol, tobacco, caffeine, nicotine, & marijuana.
See chart here: https://en.wikipedia.org/wiki/File:Drug_danger_and_dependence.svg
Furthermore, addiction is less likely when administered by a medical professional in a controlled, therapeutic, safe environment versus recreational self-administered ketamine.
Given that there could be a low likelihood of addiction, yet ketamine has the potential to alleviate one’s long-term suffering from depression or suicidal thoughts, wouldn’t it be fair for individuals (after a thorough discussion and understanding of the risk/benefits/alternatives/costs) to make their own decision?
Lastly, ketamine may actually have anti-addictive properties in patients with substance use disorders. See: “Efficacy of Ketamine in the Treatment of Substance Use Disorders: A Systematic Review.” Front. Psychiatry, 24 July 2018.
https://www.frontiersin.org/articles/10.3389/fpsyt.2018.00277/full
CHRONIC PAIN & FIBROMYALGIA:
Ketamine is a generic drug and thus no pharmaceutical company is willing to invest significant funds for research. Accordingly, the available studies are small sample sizes and limited. But this doesn’t mean it can’t be effective.
There is much overlap between chronic pain and depression and frequently occur together. Accordingly, many patients who have chronic pain are prescribed antidepressants. It’s reasonable to expect that as someone’s depression lifts then this can also help reduce their chronic pain symptoms.
From a pathophysiological approach, fibromyalgia (FM) is hypothesized to be caused from altered pain receptors (i.e. hypersensitized) and ketamine seems to “reset” those pain receptors via NMDA blockade.
There is a small study on IV ketamine for FM which showed, “a significant reduction in pain intensity during and after the test period. Tenderness at tender points decreased and endurance increased significantly, while muscle strength remained unchanged. The present results support the hypothesis that the NMDA receptors are involved in pain mechanisms in fibromyalgia. These findings also suggest that central sensitization is present in fibromyalgia and that tender points represent secondary hyperalgesia.”
Source: “Pain analysis in patients with fibromyalgia. Effects of intravenous morphine, lidocaine, and ketamine,” https://pubmed.ncbi.nlm.nih.gov/8610220/
QUESTION FOR YOU:
Who is John Galt?
All the best,
Sam
I couldn’t agree more with the above poster. This type of business presents ethical issues on many levels. An ER doc with little to no mental health training treating severe mental illness without an on site mental health provider is dangerous. Also, charging hundreds of dollars per treatment for an otherwise cheap generic drug. I think it’s safe to say most of those who opt for this treatment will have exhausted other options and will be desperate to try something promising, despite the costs.
This reminds me of services such as Roman, to treat ED, which are focused on treating only one condition. These sorts of narrowly focused businesses in medicine seem to be poor alternatives to true, comprehensive care. But at least those services are using FDA approved treatments. This ketamine clinic isn’t even doing that.
We are not aiming to become a patient’s psychiatrist or make new psychiatric diagnoses. We collaborate with patient’s psychiatrists and therapists and our patients continue to regularly see their own mental health specialist before and after treatments.
But as an ER doctor, I’m no stranger to the mental health conditions that all of our patients suffer from, and I have the training to recognize & diagnose psychiatric emergencies.
In addition, as an emergency physician, I know how to handle any potential complication that may come up during ketamine for non-anesthesic indications (KNAI). ER & Anesthesia are the two specialties most familiar with intravenous ketamine use for patients. My goal is to provide treatments in a safe, monitored, & therapeutic environment for our patients.
CHARGING FOR GENERIC DRUG
Racemic ketamine is generic and inexpensive, but time, labor, & medical training is precious. Patient’s aren’t paying for ketamine. They are paying for 10+ years of medical expertise by a physician who knows how to handle any medical issue that comes up.
Just because someone can buy scalpels on eBay (for a very cheap price) doesn’t mean they should perform an appendectomy at home.
Outpatient ketamine infusions are not typically covered by health insurance companies, but this is slowly changing as the insurance firms begin to realize that it’s actually going to save them money (and costs less than Spravato).
PATIENT AUTONOMY
Patients are doing their own research and choosing ketamine treatments on their own accord. They are making a decision to spend money on their mental health, whereas someone may choose to spend money on a Tesla.
I believe each person has the right to make their own financial decisions as they personally see fit. Just because someone is challenged from a mental health condition doesn’t mean they suddenly lose individual autonomy.
And we don’t treat patients who have a mental health condition so severe that they are incapable of making their own decisions.
NOT FDA APPROVED
Since ketamine was FDA approved in 1970 (for use as an anesthetic agent) and is now generic, it will likely never be approved for a NEW indication because no pharmaceutical company is willing to invest significant funds for Phase 1-4 trials.
However, Janssen (division of Johnson & Johnson) did get FDA approval for nasal esketamine for depression and sucidiation ideation recently. It costs $600-900 per spray. It’s also covered by insurance once patients-doctors jump through certain authorization requirements.
But a recent meta-analysis and systematic reviews show that IV racemic ketamine is better than nasal esketamine spray.
See: “Comparative efficacy of racemic ketamine and esketamine for depression: A systematic review and meta-analysis.” Journal of Affective Disorders Volume 278, 1 January 2021, Pages 542-555. https://www.sciencedirect.com/science/article/pii/S016503272032766X
Take care,
Sam
Dr. Ko, you quote the 2018 JCP study from Yale Psychiatric Hospital to support your case. Funny that you didn’t also mention the following articles by several of the same authors, which highlight the potential dangers of what you are doing. I’ve listed them below, for you and others to read. Perhaps you had a conflict of interest? (I’m guessing your bank account). I trained at Yale and know most of these author personally. Ketamine has great potential as a psychiatric treatment, and has demonstrated efficacy for MDD but not a whole lot else. There is also a lot of potential for things to go very wrong. Research is actively being done at a number of sites, but I guess you didn’t have time to wait and see. I hope you guessed right, for your patients’ sake.
Ketamine: A Review for Clinicians
https://doi.org/10.1176/appi.focus.20180012
From the abstract: “Promises of efficacy have led to increasingly unbridled use to treat a variety of psychiatric disorders, with diverse approaches and treatment environments, despite inadequate data demonstrating the true clinical efficacy and safety of the various protocols or a thorough understanding of mechanisms of action.”
From the conclusions:
“There are extremely little published data related to the use of ketamine for disorders other than major depressive disorder at this time. ”
Also see:
A Survey of the Clinical, Off-Label Use of Ketamine as a Treatment for Psychiatric Disorders
https://dx.doi.org/10.1176/appi.ajp.2017.17020239
Completely agree with this comment. There’s nothing wrong with trying to monetize a treatment that isn’t being covered by insurances that has some proven benefit for patients, but the problem becomes when *in order to monetize* the treatment’s stated efficacious uses gets broadened. On the front page of Dr. Ko’s website it literally says “Ketamine infusions to treat depression, anxiety, PTSD, and chronic pain.” Ketamine is lucrative so marketing it as a panacea for a myriad of things it actually doesn’t have evidence for makes sense from a profit-making standpoint, because if it was marketed only for the narrow use it has shown evidence of benefit for, it wouldn’t be as profitable a business.
I understand why WCI accepted the post as he commented below, but I don’t see why valid ethical and evidence-based critiques of this particular side hustle are being hand waived as generic turf critiques. If physicians are going to step outside of their area of training into a side business, learning the nuts and bolts of starting such an enterprise is important so the post definitely provides value to the community, but so are the ethics and ethical questions being brought up here in the comments. Dr. Oz could write a guest post talking about how to make money selling snake oil to millions, but that shouldn’t preclude us from discussing the valid ethical implications of doing so in the pursuit of profit. Comparing ketamine infusion clinics marketing as cure-alls to chronic pain, fibromyalgia, PTSD, and anxiety with family doctors doing botox on the side is disingenuous. And anyone considering taking up a side hustle should think about the ethics, the actual evidence, as well as the other business-related roadblocks.
I’m finding it fascinating that commenters are focusing on what the clinic does rather than the reason we accepted the post in the first place–because it shows steps and obstacles in opening a clinic. But I’m sure if it had been an aesthetics clinic we would have had plastics folks on here arguing about it and if it had been an OMM clinic we would have some allopathics docs on here arguing about effectiveness and if it had been a functional medicine clinic someone would have had a problem with it. If it had been a concierge clinic some docs would have an ethical issue with it as well.
But most of the post deals with issues that would also exist when opening a bread and butter comprehensive care clinic.
Hey, my post did address one aspect of setting up a new practice since I did it.
I am totally behind side gigs and ones that might one day replace a day job and the WCI does a great job of not only giving examples of what is out there, but also pathways to getting there beyond equity markets and real estate. I appreciate the risks and challenges taken to start this new business but I think it is important to evaluate the business itself and this author’s website includes promotion of classes on how to start Ketamine clinics so franchisement of these clinics seems like fair game for critique. I think it might be a false equivalence to compare this to aesthetic enhancements like Botox. For instance imagine a Botox clinic on every corner. Yeah, this might result in some negative Yelp reviews from unhappy customers. What is the logical conclusion of a Ketamine clinic on every corner? I imagine a wave of drug abuse. And huge backlash against not just the practitioners in the clinic but medicine in general. If a study came out that said Fentanyl makes people less suicidal, would a post about starting a Fentanyl clinic pass the sniff test? Could you really expect readers to just focus on the business aspect? It is hard to be sympathetic to the struggles of finding Ketamine during a shortage that was diverted to treating fibromyalgia in this clinic that could have gone to a hospital
Who is John Galt? 🙂
I’m a psychiatrist and the chief medical officer of a large system that provides mental health services to thousands of patients.
Do we have a Ketamine clinic? No. Did we embrace the use of the FDA approved Spravato (esketamine) nasal spray? No. But, there are three active Spravato clinics in the state and three more in the works per their “location finder.”
Might as well open a psychiatric cannabis clinic. Poor evidence, high risk, but a few steps above selling naturopathic remedies for fatigue, erectile issues, and such.
Efficacy and safety aside, it’s interesting to see someone “step outside the box” and start something new, but this particular example may not meet the “would I use it myself” smell test, like the psychiatric cannabis idea.
It takes gumption to start a new business. I think tele-health or tele-psych startups would be useful in “getting a side gig”.
Thanks for your comment, YourHuckleberry.
May I kindly invite you to consider reading the meta-analysis and systematic reviews published recently?
“A systematic review and meta-analysis of the efficacy of intravenous ketamine infusion for treatment resistant depression: January 2009 – January 2019.” Journal of Affective Disorders Volume 277, 1 December 2020, Pages 831-841. https://www.sciencedirect.com/science/article/abs/pii/S0165032720327026
“Efficacy of single and repeated administration of ketamine in unipolar and bipolar depression: a meta-analysis of randomized clinical trials.” Pharmacological Reports volume 72, pages: 543–562(2020) https://link.springer.com/article/10.1007/s43440-020-00097-z
“Ketamine for suicidal ideation in adults with psychiatric disorders: A systematic review and meta-analysis of treatment trials.” Aust N Z J Psychiatry . 2020 Jan;54(1):29-45. https://pubmed.ncbi.nlm.nih.gov/31729893/
“Comparative efficacy of racemic ketamine and esketamine for depression: A systematic review and meta-analysis.” Journal of Affective Disorders Volume 278, 1 January 2021, Pages 542-555. https://www.sciencedirect.com/science/article/pii/S016503272032766X
All the best,
Sam
Poor Whitecoatinvestor… Posts informative articles, yet forum trolls and commenters always find time to complain. You just can’t win sometimes!
Thanks Reed1! And thanks WhiteCoatInvestor for starting this website from the ground up.
I’m learning that if you’re doing anything worthwhile or different, you’re always going to have people who disagree.
Hi Dr. Ko,
Congrats on your success.
Just wondering if you see Spravato as a competitor?
Thanks
Dear M,
Thanks so much! I’m still learning and growing a lot, and I spend way too much of my free time thinking about all things ketamine-related than any normal person would.
But to answer your question: No, not at all. IV racemic ketamine is simply better. Insurance companies will figure it out soon enough.
Cheers,
Sam
Normally I enjoy WCI posts, but not this one. Ketamine clinics are not an ethical “side hustle.” As physicians, we want autonomy and we want to earn a good income. But income should be earned in an ethical way. We already have problems with drug abuse in this county and ketamine clinics just further contribute to drug abuse. And this doctor is an emergency doctor, not a pain medication specialist or a psychiatrist who are trained to treat these patients.
I have to agree with many other commenters. This business appears to have many ethical issues. It’s great to promote side hustles, but we should avoid unethical business. I’m not an expert on the use of ketamine for mental health or chronic pain (not my specialty), but if ketamine clinics are efficacious they should be run by doctors of that specialty. Not an ER doc! What are we NPs? thinking we can go around jumping from specialty to specialty after reading a few articles. so many malpractice carriers turning him down should be a red flag right there.
Pediatrician here, don’t mind me while I go open a botox clinic for people age 50+.
Dear Staradmiral,
The two medical specialties that are most familiar with intravenous ketamine administration is ER and anesthesiology. And collaboration with those mental health professionals ( who may not feel comfortable with getting IVs, pushing IV medication, managing potential airway & vital signs issues) is crucial as well!
Since outpatient IV ketamine infusions are new, the malpractice carriers were unaware of this, but with more education it was APPROVED by their committee.
Furthermore, I am a part of an organization, the American Society of Ketamine Physicians, Psychologists, & Psychotherapists (www.askp.org) which is helping to spread awareness and education regarding safe, effective and ethical therapeutic use of ketamine.
Best Wishes,
Sam
1- I’d much rather have an ER doc (or even a ICU etc experienced NP) running a ketamine clinic than a psychiatrist/-ologist! IV access and crash cart use experience needed more than psych dx skills. Some argument for asking patients to get their therapists to buy in to the tx, but the patients who really want it would switch therapists to get it in that case.
2- Having done research on guaifenesin there will never be paid for research adequate to achieve FDA approval for a new indication for a genericly available drug. [Thank you very much Red Cross and US Army for the malpractice cover and supplies and IRB approval in addition to my and my coauthors’ few years of volunteer time (OK maybe only 0.5 years FTE) to carry out the research.] If Spravato got FDA approval then ketamine, rightly or wrongly, could also do so with enough time, money, and data masturbation. Dr. Ko if you end up with too much spare time it would be easy to do some research (probably not placebo controlled double blind like I was actually able to do- no one was paying for their care in my project) although the pay off (other than publishing and more support for your- and every other KNAI clinic’s- work) is nil. Maybe if you have a kid or godchild who wants to do a project to buff their college or med school application? Start thinking about IRBs which might be amenable. Maybe you could even get the VA to fund such research?
3- prior to possibly full and final retirement (3d month now) I considered doing a naltrexone or other substance abuse med clinic to help out a psychologist in a poor Black neighborhood who recognized the need. He wanted to let me use his spare office and take his referrals until I was flourishing. I passed in the end
Longtime reader as well, and have found the site to be useful for financial advice from time to time.
But wow, what a problematic guest column. This is an egregious example, fairly far along the slippery ethical slope of for-profit entities in medicine. It might be getting confusing for the White Coat Investor, because it seems like he’s been out of medicine and in the blogging/marketing/financial game for a while, but remember, we all took an oath. And clearly, our motivation as physicians should be always be to do best by our patients, not our wallets. I watched 2 minutes of the video from the main page of Dr. Ko’s website and felt sick to my stomach. The man doesn’t even seem to know the difference between a mood disorder and an anxiety disorder. And yet he seems to have the same magic bullet for a plethora of psychiatric disorders.
Also, I’m disappointed to see the defensive response from the White Coat Investor. Sure, your intent may have been that you wanted to highlight the challenges of opening a clinic. But you chose to highlight what appears to be a business venture of a greedy quack and this is clearly having a visceral effect amongst your readers. Take some responsibility for your actions and own up to your mistake.
Thanks for the feedback on the guest post.
Why would you say I’ve been out of medicine? At 10 am this morning I had 11 patients and 6 in rooms waiting to be seen. Last I checked that still counts as being in medicine. Looks like I’m not the only one who needs to “own up to a mistake.”
Look, I don’t personally know enough about ketamine for depression to know whether this is malpractice or just a typical turf war. And I honestly didn’t even think about it before accepting and running the article. It certainly wasn’t what I was focused on, believe it or not. If you guys would prefer more guest posts on colored diamonds, we can do that. 🙂
https://www.whitecoatinvestor.com/investing-in-colored-diamonds/
Apologies for my assumption that you were no longer practicing medicine. I guess I made the assumption because it seems that you spend a lot of time working on this site. It’s commendable that you care to invest a lot of time and energy in your site, but also makes it all the more perplexing that you would then claim you “don’t know enough” about the dangers of these kind of profiteering clinics, after 5 people posted expressing just that. If you haven’t become concerned from the now 6 of us who’ve chimed in, perhaps you may want to read this article:
https://www.scientificamerican.com/article/is-the-ketamine-boom-getting-out-of-hand/
Furthermore, you may want to peruse this code of ethics for bloggers, social media and content creators, especially items 2, 3, 4, 8 and 12:
https://mor10.com/code-of-ethics-for-bloggers-social-media-and-content-creators/
Thanks for the feedback.
I’m sorry, is this psychiatrist saying with a straight face that ER docs are greedy and unethical when many in his own discipline are running private practices charging upward of $500/hr to prescribe mostly ineffective treatments?
It’s worth noting that many people cannot find psychiatrists to manage their mental health and so rely on primary care doctors for their care. I wonder why all the altruistic psychiatrists aren’t running 24hr clinics to meet their patient’s needs like primary care drs (and ER docs) do?
Primary care doctors are more than qualified to diagnose MDD, BPD, dysthymia, anxiety and the like, as well as initiate treatment for these issues. They can also prescribe opioids for chronic pain and benzodiazepines for panic disorder! Why can’t they use subdissociative Ketamine!?
Your green eyes are showing
Dear Dr. Ko,
thanks for all the work you have done and congrats on the choices you have made. You are clearly onto something if only by how badly the old guard is attempting to diminish what you are sharing. I’ve recently completed 6 sessions in another state but have benefited greatly from all the insight you share on youtube, otherwise.
Thanks again,
Patrick
I’m a medical student with entrepreneurial aspirations in psychiatry, and I find it awesome and inspiring to see Dr. Ko overcoming these entrepreneurial challenges and offering people such a valuable service.
Admittedly, I may have biases with regards to ketamine: I’ve learned from researchers at Yale investigating ketamine in the treatment of depression and borderline personality disorder, spoken with clinician researchers using ketamine as part of treatment alcohol and cocaine addiction, and collaborated with psychiatrists who’ve used ketamine in conjunction with intensive psychotherapy to treat depression and other psychiatric conditions. All that to say, I’m optimistic that approaches like the one Dr. Ko’s following can offer tremendous benefits for people with a range of psychiatric conditions—not just depression—and that the harms and risks can be substantially reduced with adequate forethought and attentiveness.
Yes, the current cost to consumer can be frustratingly high, though I don’t know if it’s fair to focus the blame for this issue on clinicians given the roles patent law and insurance companies play. Hopefully systematic changes will be made so that these interventions can be more affordable and accessible.
I don’t know much about ketamine but just wanted to comment on how impressed I am by the resilience of Dr Ko and his ambition. Never give up and believe in your goal. Well done!
What a great article and inspiration Dr. Ko! You have overcome so many hurdles.
You have many people who depend on you and there aren’t many caring and courageous doctors like yourself out there.
I’m lucky enough to have one like you in Arizona who has literally saved my life. She’s a surgeon who does ketamine infusions also. We have eradicated my diabetes and lowered my high blood pressure with fasting and diet and I’m no longer on meds for those issues (meds she put me on initially). I get relief from my debilitating fibromyalgia, pain and depression that have ranged between an 8-9, for about 2 decades, down to a 2-3 for weeks at a time with Ketamine infusions. And she’s also got my thyroid in normal range, after diagnosing me with Hoshimoto Thyroiditis. I was a mess when I met her less than a year ago.
I studied altered states of consciousness in my college years and was a big supporter of MAPS back in the day. I had read Dr. Karl Jansen’s book “Ketamine: Dreams and Realities” circa 2001 and was shocked that Ketamine was not being used as it had proven so effective in treating addiction, PTSD, depression, etc. I had impossible to treat major severe depression and had been on every drug and drug combo and had even gone as far as 3 ECT treatments with loss of memory. I was in therapy for years as a teenager with so many different psychiatrists, psychologist, MD’s for medical, etc. all were totally useless in helping me get any relief. When I found out Ketamine was being offered, it gave me hope, and it turns out, rightly so!!!
You and my doctor have patients that vote with their hard earned dollars. Most doctors “earn” insurance dollars. I wonder how many patients they’d have left if they lost their ability to take insurance?
I have full coverage and had not seen a doctor in over a decade because I had jumped off the ineffective, apathetic allopathic, drug dealing, dinosaur medical merry-go-round long ago.
A reminder to the doctors commenting here – People have a right to assess the risk to benefit ratio for themselves as free citizens of our once free Constitutional Republic. It’s literally what our founding fathers fought and died for… individual liberty! How far we have strayed into a “ban everything” cowardice nation with venomous doctors who sell their souls to big pharma and criminal government agencies at the expense of their patients.
And then attempting to pressure and shame this platform for carrying Dr. Ko’s inspirational and informative article – shame on you! You’re acting like ignorant jealous children having a tantrum. Good grief!
I would love to come to Dr. Ko’s clinic the next time I’m in California. Thanks for all you and other trailblazing doctors are doing to truly help your patients live better lives. It’s the road less traveled and I for one understand the risks and sacrifices you make to help people like me.
Love and respect,
– N. Nelson
Which insurance company finally wrote the malpractice coverage?
I enjoyed your article. Unfortunately I found it a little late. I had also just opened a practice just before covid and had to deal with the same stressor’s. Late last year I decided that I wanted to steer my office towards a ketamine center. I spent some time in training as well as preparing rooms, purchasing equipment and hiring a new RN. Then I was clobbered by the smallest of details. Most distributors quit selling ketamine unless you were an anesthesiologist or psychiatriast. I guess they feel it’s their place to determine who practices “good medicine.” 🥴 But eventually I was able to procure it and plan to start infusions 4/18/22. Still haven’t gone live with my new website, but that will happen shortly. Everything you mentioned proved to be true. I hope that your practice is doing well.
Hello,
Can an Entrepreneur open a Ketamine Clinic in Florida?
Sure, why not?
Could someone who graduated medical school and passed all 3 step exams but never graduated residency open a ketamine clinic?
If you’re licensed to practice medicine I think you probably can. Whether you should or not is a different question.
Very astounding to see that during what many are characterizing as a mental health crisis, that physicians who are offering novel, effective, off label uses of medications they are familiar with using and are board certified to use are being criticized by turf warriors who think that these medications should only be administered by select specialties. It’s worth noting that many Emergency Physicians are quite experienced in dealing with psychiatric illness and do so daily. The shortage of competent psychiatrists has led most primary care physicians with the role of taking care of mental health, and emergency physicians are uniquely poised and experienced to administer subdissociative doses of ketamine. It’s approved and safe for use in children for crying out loud. I see no ethical issue here. Dr. Ko is providing a medical service that is effective and popular and has very low risk of addiction – and this is borne out in the literature. Furthermore, is the same criticism being levied against psychiatrists who have private practices and charge $600/hr? The plain fact is that psychiatrists are uncomfortable practicing with medicines such as these and haven’t taken up the gauntlet. I see jealousy of entrepreneurial boldness masquerading as ethical grandstanding.