Episode 63 - Opening a Ketamine Clinic: An Unconventional Path for Emergency Physicians (Episode From The Vault)
Sam Ko shares the clinical evidence, honest financial realities, and the career pivot case for emergency physicians and clinicians considering opening a ketamine therapy clinic.
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 Learn in This Episode:
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 moments
Key Takeaways:
The mental health crisis is not slowing down. With over 300 million people affected by depression globally, suicide rates up 33 percent since 1999, and SSRIs falling short for the majority of patients who try them, there is a genuine clinical need that IV ketamine is well positioned to address.
The clinical evidence for IV ketamine is substantial and growing. The 2023 NEJM trial found IV ketamine to be non-inferior to ECT for treatment-resistant depression, and a subsequent JAMA Psychiatry analysis suggested outpatients with moderately severe to severe depression may consider ketamine over ECT. Studies in anxiety and PTSD show similarly promising results.
Emergency physicians are not starting from zero. Familiarity with ketamine administration, experience managing patients with mental health conditions and chronic pain, comfort with monitoring and procedures, and scheduling flexibility all translate directly and meaningfully into the ketamine clinic setting.
Do not open a ketamine clinic for the money. Sam is direct about this. The uncompensated hours spent on marketing, HR, ordering supplies, and running the business mean that financially, full-time emergency medicine may actually come out ahead. The real case for opening a clinic is purpose, autonomy, and the quality of the work itself.
Your why is not optional. Starting a private practice is hard. Business will be slow at first. Colleagues may question the decision. Without a clear and deeply felt reason for doing it, the challenges are difficult to sustain through. With one, they become manageable.
Listen to the episode on Apple Podcasts, Spotify, Overcast, or on your favorite podcast platform. Watch the discussion on YouTube here.
Episode 63 show notes:
00:00:00 Teaser: "This is the why, the purpose, the motivation."
00:00:34 Episode Introduction and Overview
00:01:45 The Mental Health Crisis: Why This Work Matters Now
00:03:48 Burnout and the Changing Landscape of Emergency Medicine
00:04:43 Why EM Physicians Are Uniquely Positioned for Ketamine Therapy
00:05:02 The Clinical Evidence for Depression: From the Berman 2000 Study to the 2023 NEJM Trial
00:07:25 The Clinical Evidence for Anxiety: Dr. Paul Glue's Escalating Dose Study
00:08:20 The Clinical Evidence for PTSD: Single and Multiple Infusion Data
00:09:41 The Clinical Evidence for Chronic Pain: What Works and What Doesn't
00:10:55 Mid-Episode Ad: Free Ketamine Startup Checklist
00:11:44 How Ketamine Works: NMDA Receptor Antagonism and Glutamate
00:12:19 Multi-Receptor Action, Neuroplasticity, and BDNF
00:13:30 Beyond the Mechanism: The Experiential Dimension of Ketamine
00:14:40 The EM Skill Set Advantage: Clinical Experience, Procedures, and Scheduling Flexibility
00:15:24 Emergency Medicine Is a Mindset, Not a Location
00:15:53 Before the How, There Is the Why
00:16:39 The Toxic Waste Pool: A Story About Purpose and Motivation
00:17:23 The Financial Reality: Don't Open a Clinic for the Money
00:18:14 Why You Should Open a Ketamine Clinic: Purpose, Autonomy, and Saving Lives
00:18:55 Patient Testimonials: In Their Own Words
00:20:17 Outro
Thanks for Listening
Resources & Links From This Episode
🎥 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 YouTub
📖 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
📌 Ready to take the next step? This blog post is the practical follow-up to everything covered in this episode:
How to Start a Ketamine Clinic: 3 Key Questions for Emergency Medicine Physicians
If your why is clear, these three questions will help you determine whether the how is viable for you right now.
Professional Education Disclaimer: This content is intended for licensed healthcare professionals considering or actively building a ketamine therapy practice. The clinical information presented reflects published research available at the time of recording and is shared for educational purposes only. It does not constitute medical advice for specific patients or clinical situations, and treatment decisions should always be based on individual patient assessment, current literature, and adherence to professional medical standards. The business and financial information shared reflects Sam Ko's personal experience building and operating a ketamine clinic and should not be taken as a guarantee of specific outcomes. Opening and operating a ketamine clinic involves significant clinical, legal, financial, and regulatory considerations that vary by state and practice context. Always consult qualified legal, financial, and medical professionals before making significant practice decisions.
Frequently Asked Questions
Is IV ketamine actually supported by clinical evidence for depression treatment?
Yes, and the evidence base has grown significantly since the first small proof-of-concept study published by Dr. Berman and colleagues in 2000. A meta-analysis synthesizing roughly a decade of data confirmed that IV ketamine can be effective for depression. Most notably, a 2023 trial published in the New England Journal of Medicine compared IV ketamine directly to electroconvulsive therapy, currently the gold standard for treatment-resistant depression, in 400 patients and found ketamine to be non-inferior. A secondary analysis published in JAMA Psychiatry in 2024 went further, suggesting that outpatients with moderately severe to severe depression may consider ketamine over ECT for their symptoms.
What conditions can IV ketamine therapy address beyond depression?
IV ketamine has been studied across several conditions with promising results. For anxiety, a study by Dr. Paul Glue found that 83 percent of patients with generalized anxiety disorder, social anxiety disorder, and panic attacks reported greater than 50 percent reduction in their anxiety scores, with effects lasting up to seven days and improving further with multiple infusions. For PTSD, studies published in JAMA Psychiatry demonstrated significant symptom improvement with both single and multiple infusions compared to active placebo. For chronic pain, IV ketamine appears most effective for neuropathic pain and conditions involving central sensitization, such as complex regional pain syndrome, fibromyalgia, trigeminal neuralgia, postherpetic neuralgia, and peripheral neuropathy. A systematic review meta-analysis on ketamine infusions for chronic pain found that benefits may last up to two weeks following treatment, and suggested that higher doses and longer durations of infusion tended to be associated with greater effectiveness.
How does IV ketamine work at a mechanistic level?
Ketamine is an NMDA receptor antagonist that works primarily on the neurotransmitter glutamate, which comprises approximately 90 percent of neurotransmitter activity at synapses. Chronic stress associated with depression, anxiety, PTSD, and chronic pain is thought to raise extracellular glutamate levels, leading to excitotoxicity and a reduction in dendritic connections in the brain. Ketamine may reverse this by increasing brain-derived neurotrophic factor, which promotes protein synthesis, synaptic strength, and synaptogenesis. The net effect is neuroplasticity, a reopening of critical learning pathways and a resetting of pain receptors. Ketamine also acts on a broad range of other receptors including opioid, dopamine, serotonin, acetylcholine, and GABA, making its mechanism more complex than a single-receptor drug like a selective beta blocker.
Why are emergency physicians particularly well suited to open a ketamine clinic?
Emergency physicians bring several advantages that translate directly into the ketamine clinic setting. Most have already administered IV ketamine and are familiar with its dosing, adverse effects, and monitoring requirements. They have significant clinical experience managing patients with depression, anxiety, suicidal ideation, and chronic pain. They are comfortable with procedural monitoring and patient sedation. And the scheduling flexibility of emergency medicine, including the ability to reduce shifts or build in blocks of time, makes it more feasible to build a side practice than it might be in other specialties. Sam also makes the broader point that emergency medicine is a mindset, not a location, and that the clinical judgment and adaptability EM physicians develop transfers well into an entrepreneurial medical setting.
What are the financial realities of opening a ketamine clinic that providers should understand before starting?
Ketamine therapy is cash pay and not covered by most insurance plans, which means revenue depends entirely on patient volume and out-of-pocket pricing. Sam is candid that the hours spent on marketing, staffing, ordering supplies, and running the business are largely uncompensated, and that a provider working full-time emergency medicine may actually earn more than one splitting time between EM shifts and clinic operations. The ketamine clinic is also not something you clock in and out of. It stays on your mind in a way that a shift-based job does not. Sam describes it as being like having a newborn. The financial case for opening a ketamine clinic is not primarily about income. It is about autonomy, flexibility, purpose, and the quality of the clinical work itself. Providers who open a clinic primarily for financial reasons are likely to find the reality harder than expected.