Episode 67 - Ketamine, Pain, and Private Practice: Inside the Multimodal Clinic Model with Dr. Zach Fisk
Dr. Zach Fisk shares how he built a ketamine and pain practice from scratch, including dosing philosophy, insurance realities, and clinic-building advice.
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 Learn in This Episode:
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 for
Key Takeaways:
Ketamine becomes more powerful when it is part of a comprehensive clinical model. Dr. Fisk describes ketamine not as a standalone business but as one deeply integrated tool within a practice that also offers regenerative medicine, peripheral nerve stimulation, nerve blocks, and psychiatric support. For providers thinking about how to position ketamine in their practice, his model offers a compelling alternative to the single-modality clinic.
The insurance landscape for IV ketamine is genuinely difficult to navigate safely. Dr. Fisk's experience includes unexpected early coverage, clawbacks from Aetna and Regence, and a voluntary repayment of Medicare revenue on legal advice. His conclusion is that the combination of clawback risk, administrative complexity, and patient confusion that comes with billing insurance for ketamine makes cash pay the more sustainable model for most practices, even though he is candid about the access implications of that decision.
Outpatient sublingual ketamine can be a valuable tool when used with appropriate structure and monitoring. Dr. Fisk adapted a protocol developed by Dr. Lucinda Grande and has found sublingual ketamine effective for helping patients with chronic pain reduce or eliminate opioid use. He does not prescribe it as a standalone psychiatric treatment, citing his anesthesiology training as the boundary he works within, but acknowledges that psychiatric benefits often follow as a meaningful side effect.
Opening a private practice is not for most people, and knowing that before you start matters. Dr. Fisk is unusually direct about this. The transition from guaranteed salary to small business ownership means that a slow day as an employee is a relief and a slow day as an owner is a source of genuine anxiety. His advice is not to discourage the leap but to make sure anyone considering it fully understands the trade-offs, has a solid business foundation, and ideally a consultant who can help them build it right from the start.
Listen to the episode on Apple Podcasts, Spotify, Overcast, or on your favorite podcast platform. Watch the discussion on YouTube here.
Episode 67 show notes:
00:00:00 Teaser: Risk, Stability, and Building Something of Your Own
00:00:17 Welcome and Meet Dr. Zach Fisk
00:01:43 Dr. Fisk’s Path: Tufts, Anesthesia, and Acute Pain Fellowship
00:02:35 The Idea for an Outpatient Perioperative Pain Clinic
00:03:56 Why Ketamine Became a Primary Service, Not a Background One
00:06:19 The MD/MBA Path and How Business Training Shaped the Practice
00:09:18 From Fellowship to the VA: Building an Acute Pain Service
00:10:21 Leaving a Stable Job When You Want to Build Something
00:11:31 “We’ve Never Been Trained in Business, So I Just Went for It”
00:13:21 Year One Reality: Two Patients in the First Month
00:14:00 Early Hiring Mistakes and Why a Startup Consultant Made the Difference
00:15:32 What Medical Training Never Teaches: HR, Finance, and Practical Skills
00:20:00 The VA Chief Who Called It “Dead in the Water”
00:22:08 The 80-Year-Old Test: Taking Risks While You Still Can
00:26:00 Inpatient vs. Outpatient Ketamine: Dosing, Duration, and Monitoring
00:31:34 One-Hour Infusions and a Two-Titration Protocol
00:33:05 Why Body Weight Is Not the Best Guide to Dosing
00:36:50 Building a Multimodal Practice: Services Beyond Ketamine and SGB
00:41:47 Patient Stories: When Ketamine Changes and Saves Lives
00:43:10 Patient Selection and Honest Conversations About Success Rates
00:44:40 Outpatient Sublingual Ketamine and the Lucinda Grande Protocol
00:47:52 The Insurance Journey: From Clawbacks to Cash Pay
00:51:40 The Spravato vs. IV Ketamine Insurance Mystery
00:55:03 Advice for Anesthesiologists Considering Private Practice
00:57:31 Rapid-Fire Questions Begin
01:02:42 Where to Find Dr. Fisk and a Tip on Naming Your Business
01:04:33 Episode Ending
Thanks for Listening
Connect with Dr. Zach Fisk
Acute Pain Therapies Website https://acutepaintherapies.com/
Selected Links From the Episode:
The American Society of Ketamine Physicians, Psychotherapists & Practitioners https://askp.org/
The American Academy of Pain Medicine (AAPM) https://www.painmed.org/
Professional Education Disclaimer: This content is intended exclusively for licensed healthcare professionals and should not be used by patients for self-treatment or self-education. The information presented reflects individual provider experiences and should not replace clinical judgment, professional training, or comprehensive research. Healthcare providers must conduct their own due diligence, consult current literature, and evaluate treatment approaches within their specific practice context and regulatory environment. This educational content does not constitute medical advice for specific patients or clinical situations - treatment decisions should always be based on individual patient assessment and adherence to professional medical standards.
Frequently Asked Questions
What makes a multimodal pain clinic different from a standalone ketamine clinic?
A multimodal pain clinic integrates ketamine as one of several therapeutic tools rather than the sole offering. At Acute Pain Therapies, Dr. Fisk offers ketamine alongside stellate ganglion blocks, regenerative medicine including PRP and mesenchymal stromal cell injections, peripheral nerve stimulation, spinal cord stimulators, radiofrequency ablation, and outpatient sublingual ketamine prescribing. In his framing, ketamine is the primary service rather than a background support, which is the opposite of how anesthesia is traditionally used. The practice treats patients with chronic pain, depression, or both.
What is the difference between how ketamine is used in an inpatient versus outpatient setting?
In the inpatient program Dr. Fisk ran, ketamine was given as a very low dose continuous infusion, around 5 to 20 milligrams per hour in total, over several days to supplement postoperative pain relief. At that dose, he notes, side effects are minimal, if present at all. As an example of how outpatient care can look different, Dr. Fisk explains that patients in his clinic cannot be watched by nurses for days, so infusions typically run between one and four hours, and in his experience the dose generally has to be higher. Other clinics may approach this differently. Dr. Fisk also describes a different category of inpatient ketamine presented at an ASKP conference, involving very high doses over multiple days in an ICU setting, reportedly for complex regional pain syndrome. A physician he spoke with described needing a Foley catheter and electrolyte monitoring because of heavy diuresis. Dr. Fisk relays this as a secondhand account and notes it is not the kind of inpatient program he ran.
How does Dr. Fisk approach outpatient sublingual ketamine prescribing and when does he use it?
Dr. Fisk adapted a protocol developed by Dr. Lucinda Grande for sublingual ketamine syrup, which uses specific patient criteria to determine a starting dose. He describes it as a tool that does not work for everyone but can be very effective for helping people with chronic pain and helping people stay off opioids. He does not prescribe outpatient ketamine specifically for depression, explaining that prescribing it only for a psychiatric indication moves away from his core anesthesiology training. It can help patients psychiatrically as a side benefit when prescribed for pain. He disagrees with a lecturer who reviewed bad outcomes with high-dose ketamine lozenges from a mail-order company and concluded that outpatient ketamine should never be prescribed. In Dr. Fisk’s view it can be very effective and very safe, but it needs monitoring like opioids do. As a pain clinic that already prescribes opioids and other medications, his practice has the infrastructure to do that safely.
What is Dr. Fisk’s advice for anesthesiologists or pain physicians considering opening their own private practice?
Dr. Fisk’s first point is that opening your own private practice is not for most people. As an employee, a light day is a welcome break. As a business owner, a light day can feel catastrophic because you wonder whether you can pay the bills that month. His second point is that an anesthesiologist without chronic pain fellowship training has a very hard road ahead, while one with that background can find opening a clinic feasible, though still extremely difficult. Ketamine, he notes, is an option. His third point is that a consultant can be extremely valuable for anyone without a business background. He credits his own consultant with helping on fundamentals, from improving his credit score to qualify for a practice bank loan to covering things he had not thought of, and says it would have been much harder without that help. He adds that his MBA helped him analyze the market and competition and build a financial model. His overall message is to understand the trade-offs: you can be the master of your own life and set your own schedule, but you will constantly worry about the health of your business.