My Journey of Starting Up A Ketamine Clinic

Please note this is a transcript of the talk that was given, and has been edited for readability.

ROB - YPSG

Well, first of all, thank you, everyone, for showing up tonight for this presentation. I've been excited about this for months and I'm super grateful to Dr. Ko for coming to talk with us about his work with ketamine -- which is something that we as Yale Psychedelic Science Group have been talking about and listening to outside speakers for years now. And I'm very excited to hear Dr. Ko share his approach and his journey using ketamine. 

Just as a bit of background, I actually met Dr. Ko back in early 2016 before I even started medical school. And I was really, in a personal way, very inspired that there was someone with an MD after their name who is interested in using psychedelics as part of clinical care. At that time, I felt like a lot of folks who were kind of in-the-closet about that subject matter. But to meet someone who is a physician and motivates you to do this kind of work was inspiring for me because I thought I was one of the only people who was open to talking about these things. 

Over the years, I’ve stayed in touch with Dr. Ko who had this idea of starting a ketamine clinic years ago, and now made it a reality. So, I am super inspired by his own journey. 

From what I know when I first met him five years ago to where he is today, I think he's doing really great work. And so I was really motivated to have him come speak to us because I think he brings a valuable perspective that we don't hear a lot about. This is both the perspective of someone who is motivated to help people heal from whatever's ailing them, but also is a little bit of financial and business savvy if you will.

Dr. Ko has this entrepreneurial spirit and he's kind of been in the trenches doing this as a business owner, which is I think something that is going to become more and more the norm, whether it's with ketamine or psilocybin or MBMA or whatever else might be coming down the pipeline. 

And so learning from folks like Dr. Ko, who are establishing these businesses to help people using ketamine or whatever other psychedelics are at their disposal, I think it's something that I know we in the leadership are really excited to learn more about and us going to become more and more of a topic of conversation. 

After that very long introduction, I want to turn things over to Dr. Ko and just thank him again so much for coming to speak to us today.

DR. KO

Awesome. Thank you, Rob. And it is an honor to be at the Yale Psychedelic Science Group. I am super excited to give this presentation and there's a little QR code on the website so if you want to get access to the slides and some other stuff, some downloads, you can go in and capture that with your phone. 

That way, you'll just have access to all of the slides. Let's get started. 

Here's what we're going to be covering today. There'll be three parts: 

• Part 1 - the current state of depression and the psychedelic community 

• Part 2 - Turning research to actual practice: How I opened my ketamine clinic

• Part 3 - our approach to ketamine infusions and some case reports.

A few disclosures before we begin. First off, this is going to be a discussion of ketamine for off-label use. 

I am also the founder and medical director of Reset Ketamine, which is in Palm Springs, California. I'm also the co-creator of a course called Ketamine Startup. It's an online course for physicians. 

And lastly, this presentation is not a substitute for getting professional, legal, and accounting advice for any startups that you may decide to pursue.

So let's jump into it.

Due to an increasing prevalence of depression in both adults and teenagers, especially concerning these days is COVID-19 and its impact on our mental health, there is a need for more effective treatment options

Part 1: The current state of depression and psychedelics.

Depression is a really important topic because according to the World Health Organization (WHO), depression has now surpassed HIV, Aids, Malaria, diabetes, and war as the leading cause of disability, worldwide. 

16.2 million Americans have experienced a major depressive episode. Depression is much more common in females than males: about 8.5 versus 4.8%. And some studies are reporting that up to 20% of teenagers actually experienced depression even before they reach a buildup. 

And there's also just in general, an increasing prevalence of depression in both adults and teenagers, especially concerning these days is COVID-19 and its impact on our mental health. There's increased loneliness, isolation, there's fear of friends, family catching COVID-19. There are employment uncertainties, as well as increasing rates of depression, anxiety, and substance abuse.

One of the major concerns with depression, of course, is that it can lead to suicide. About 800,000 people die by suicide every year, and according to the CDC, the national suicide rate has increased 33% from 1999 to 2017. 

Suicide is also the second leading cause of death for Americans between the ages of 10 to 34 years of age. And believe it or not, there are twice as many suicides as there are homicides in the United States. Right now, we're kind of at this place where the suicide rate is at a 50-year peak in America.

And what is the traditional current main state for treatment? 

Those are SSRIs. And as you may or may not know, SSRIs aren't body effective, and for about 33% of patients, they can take weeks to months to kick in. There are also significant side effects: loss of libido, weight gain, insomnia, anorgasmia, and even suicidal thoughts. 

Studies have shown that for patients who take SSRIs, there's actually a 33% higher mortality rate than those who don't. 

What this leads to is that we need more options available to us. As you're well aware of, there is an explosion of psychedelic research going on with MAPS, Imperial college of London, Johns Hopkins, Harvard, UC Berkeley, NYU, and Yale. And we're studying substances like MTMA Psilocybin, LSD, Ibogaine, Ayahuasca, and 5-MEO-DMT.

We also know that psychedelics are becoming more recognized and more common. For example, Michael Pollan has his books 'How to Change Your Mind' and ‘This Is Your Mind on Plants.’ 

So this is definitely in the zeitgeists.

Unfortunately, one of the biggest challenges that we have is all of those substances that I've mentioned are currently classified as DEA Schedule 1. That means that it's not readily available for our patients in the clinical setting, mainly just in that research area. 

Now, given this situation, what is currently available? 

Ketamine is the answer. 

As you're aware of from previous presentations, ketamine is a really old drug. It was invented in the 1960s and FDA approved in 1970. It's probably the most commonly used medication for sedation worldwide and the World Health Organization (WHO) considers it one of its most important essential medications for hospitals to have.

More recently, starting in the early 2000, there have been reports. Initially these were small studies, where they're looking at the effective ketamine for depressed patients, as well as for suicidal thoughts. 

And since one of the first studies published by Dr. Berman in the past 20 years or so, there's just been multiple publications coming out. 

It has led to med analysis such as one more recently published last year, December 2020. This is a systematic review and meta analysis of the efficacy of IV ketamine infusions for treatment-resistant depression, where they just looked at all the articles. The bottom line of the study is that they found ketamine to be an effective alternative for treatment-resistant depression. 

So, given this research and all of the data, how do we actually turn it into a clinical practice? 

This is where I want to share with you a little bit about my journey, about how I started a ketamine clinic.

The journey to starting a ketamine clinic is full of planning and knowing your WHY.

Part 2: Turning research to actual practice: How I opened my ketamine clinic

In medical school and residency, we're taught about anatomy, biochemistry, pathophysiology, differential diagnosis, treatment plans, but we're not really taught how to create our own medical practices. 

What's interesting is that a recent study by the AMA showed that the vast majority (47%) of practicing physicians these days are employed by a large healthcare organization versus about 45% who own their own private practices. 

And what I make of it is that this loss of autonomy can contribute significantly to burnout, which is one of the major challenges facing the healthcare industry. 

Another challenge is when doctors don't have that freedom to practice the way they want to. 

There's this great quote, "The three most harmful addictions are heroin, carbohydrates and a monthly salary." 

So as physicians, we're kind of caught with these golden handcuffs where we're going to get paid really well, but at the same time, we may have these large student loans or other financial burdens that prevent us from doing our own thing and taking ownership of our practices.

For me, given the golden handcuffs, I had to start with knowing my why. And if you're considering starting up a practice, you really have to ask yourself, “why am I doing this?” This is your first step on the journey to starting your own ketamine clinic.

And my “why” was a combination of autonomy, freedom, practicing the way I want to practice, as well as this concept from a Japanese word called Ikigai. 

And Ikigai refers to living your life's purpose. It's a Venn diagram, combining four circles: what you love, what the world needs, what you can be paid for and what you're good at. And so for me, knowing my “why” or Ikigai really contributed to the obstacles that one faces as I started up the ketamine clinic. 

When I first started my ketamine clinic, I asked myself these questions:

• “Why am I doing this?” 

• “What's my goal?” 

• “How does it align with my life’s purpose?”

Ikigai refers to living your life's purpose.

The second thing is to create a name and a logo and this is really important. 

My wife and I recently had a baby in the middle of the pandemic. And one of the first things for those who have children or any pet, for example, is to create a name for it.

And from a business perspective, the logo is almost like a visual representation of what your vision, mission, and values are. 

Let's talk about Reset Ketamine's logo as an example.

We have the reset button in the middle because ketamine potentially resets the default mode network. And we believe our patients are naturally creative, resourceful, and whole, and our goal is really to reset our patients so that they can go back to living a whole, healthy life.

The second component of the logo is the wings. This is about the freedom that one will feel after getting their ketamine treatments. It also represents that psychedelic experience that one may experience during their ketamine infusions.

At Reset Ketamine, we made sure that our logo represented what we believe in.

Step three is to write up a business plan. 

The previous step was related to the right side of the brain. And for this step -- writing the business plan -- is more of a left brain activity. 

This is really important, especially if you're going to be getting investors for your clinic, or if you're going to be getting a bank loan. That's one of the requirements for getting financial funding. 

But even if you're not planning on getting an investment from investors or VC or getting a bank loan, just doing the exercise is really important because that's going to provide you with an opportunity to logically think through each step. You’ll be able to identify any weaknesses or opportunities. 

And if you go to this link, you'll find I put in a business plan template specifically for ketamine clinics which you can download.

After that, you're going to want to incorporate your clinic. 

This is something again that we're not really taught in med school/residency. 

One of the important things to do is to incorporate your practice because that's going to separate your personal assets from the business and clinical assets. And once you incorporate, and there's various incorporations, you can have an S-Corp, a C-corp, an LLC, and that's something that you're going to want to discuss with a business attorney. 

From there, you can obtain something called an EIN, which is kind of like a social security number for businesses. Then you can create bank accounts for your business. Finally, you are now able to enter agreements and contracts under the business name.

The fifth step is to find a location and sign a lease. 

Some of the factors that you want to consider when you're opening up and finding that perfect location are the patient demographics, competition, if there are other clinics, proximity to other medical practices, and how visible that clinic space is in regards to whether it is a high traffic or low traffic area.

This is a crucial juncture because when you sign a lease, you really have skin in the game, because you're going to sign a lease for a one-year, two-year contract, five-year contract, or even a ten-year contract, possibly. And when you're going to sign your name, you have to say, "Hey, I'm going to lease the space or there's going to be consequences afterward. "

Also, when you get your location, there are going to be initial investments for building out the space. And that's where you're going to put in multiple, thousands of dollars into it. 

So having this skin in the game is really important. It's a pretty major step, and for me, this was kind of an area where I was just putting money into the clinic. And there was a bit of fear to be honest, because it's like, "Hey, what if I open up this clinic? What if no one shows up? What if I sign a lease and I have to break the lease, or how am I going to end up paying for this?” 

But there's something really powerful about having your skin in the game, because then I knew I had to make this happen no matter what.

Step six is to get insurance. 

And I know probably the most common one you're thinking about is malpractice insurance, but there's other insurances that you need to have.

Insurances like general liability, commercial property, workers' compensation, business income insurance, etc. And there's a host of insurances. 

One of the major ones, of course, is malpractice insurance. 

When I started about three years ago, ketamine infusions were pretty new, and this was one of the challenges that I had where I talked with an insurance broker and he shopped around to all these different insurance companies and they came back and they said, "Hey, we're not going to cover you." 

That was pretty devastating because obviously, I need malpractice insurance to begin the clinic. So, this was where I had to get a bit creative and reframe it in such a way that, "I'm going to face this obstacle and this obstacle is actually a way for me to prove how badly I want it.

When you're starting up something new, there's going to be obstacles and it's all about reframing it. 

What I did eventually was I contacted one of the insurance firms and I asked them to speak with their senior underwriter. And I literally had like a 90-minute conversation with her showing her all the details, studies, and what we’re planning to do. And she was able to get an audit and bring it up to the committee where they were able to discuss it. 

A week later, I got an email saying my clinic is now approved for malpractice insurance coverage!

For step 7, you’ll want to buy your supplies and your medications. 

Here are some of the things you're going to need:

• IV fluids

• IV setups

• The machines

• Sharps like IV catheters and needles

• Syringes

• Medical equipment

• Tapes and gauze 

And I’ve normally never dealt with ordering any of these things. For us in the medical field, traditionally the supplies are already taken cared of. But as a business owner, you're going to need to know where to buy and source everything.

Fortunately, there're firms like McKesson, Henry Schein and other medical manufacturing companies who can supply that for you. 

And this is a picture of me and my wife once we signed the lease and bought all our supplies.

When we opened our ketamine clinic, we were super proud, happy, and very excited. This was it!

In our ketamine clinic, we focus on the bio-psycho-social model and decided to add a fourth component, which is the spiritual aspect.

Part 3: Our approach to ketamine infusions and some case reports.

In our clinic, we really start with the definition of health from the WHO, and they define it as a "State of complete physical, mental, and social well-being not merely the absence of disease or infirmity.” 

I did my training at University of Rochester in New York, and that's where the bio-psycho-social model was founded. I also added a fourth component, which is a spiritual aspect.

We believe in a more holistic approach for our patients during their ketamine infusion treatments.

This is the kind of framework that I take as we do the ketamine infusions. 

We talk a lot about mind and body, and one of the things that I'm learning is that it's all connected. 

Here's the map of Arizona, California, and New Mexico.

If you go to Google maps, there's this clear delineation between each area. But when you actually go to these borders, there's nothing except maybe a little sign.

And again, it is really important to understand the connection between the mind, body and spirit. Everything is interconnected. 

One example of this is the Takotsubo syndrome, also known as the broken heart syndrome. This was a case report based out of Japan where a patient experienced a severe emotional loss. She felt like she had a broken heart and so she goes to the emergency department, they see ST elevation on her ECG, and when they take her to angio, her coronary arteries are cleared.

So they wonder what’s going on. 

When they did an echocardiogram, they found that she had this abnormally-shaped ventricle, which looks like an octopus trunk. And so this is where the name Takotsubo Syndrome comes from.

The Broken Heart Syndrome is an example of where these emotional experiences we have can create these physiological changes to our organs.

Going from that framework, there are four phases of ketamine infusions at Reset Ketamine.

Phase 1: Preparation

This is where we tell our patients, even 4-5 days before the ketamine infusion, to start doing these healthier practices like meditation, journaling, being in nature, avoiding violent movies, avoiding pornography, avoiding any triggers. This helps to get the mindset in place.

Phase 2: Intention

Our patients need to be really clear on what their goals are prior to the ketamine infusion and focus on that throughout the experience.

Phase 3: Experience

This involves experiencing the experience. Being with the ketamine infusion as it goes, it creates these non-ordinary states of consciousness, and we really want the patient to be connected with that. We even have eye shades and headphones to really set the mood. The treatment is really like an internal experience and doesn’t involve much talking so the patient can really connect with themselves.

Phase 4: Integration

This is really crucial for ketamine and just for any psychedelic substance in general. It’s asking yourself “How do I take these transcendental, profound experiences and bring it home into my daily life?”

Case Studies

For case studies, we'll go with patient A. 

Patient A is a 55-year-old male and has a history of treatment-resistant depression. He's tried SSRIs and SNRIs which weren’t really working.

He came to us for treatment. And one of the things that we do at our clinic is measurement-based care. This means with each infusion, we're giving them a PHQ-9 so that we can assess how they're doing. 

When he first came in, his score was a 17 and with each progressive infusion, it decreased. And what's interesting is by the end, his PHQ-9 was less than five.

And he said, afterward, "My depression is simply gone. Now I can mold my life the way I want it. I can't remember when it felt so good. Thank you so much for your help. I feel like I have a future now.”

I think I emailed him about a year afterward and just after that initiation portion, he told me, "Hey, actually, started a new job. I'm just doing great. I'm feeling better.” What was interesting was how long-lasting it was. It's not for every patient because some patients frequently need maintenance infusions, but this patient was doing really well.

The second patient is a 43-year-old female military veteran. She had anxiety,  treatment-resistant depression, PTSD, and chronic pain. She was in the military for many years. 

And what was interesting is during the ketamine infusions, one of the things we do as I've mentioned is we let them wear blindfolds. And with each infusion, they were just covered with tears. We had to replace the eyeshades each time because it was literally drenched. 

When we were talking with her, she told me, "For 20 years, I never cried. I was in the military. I grew up kind of with this machismo culture, and I was not allowed to cry. That's just frowned upon." 

During her ketamine infusions, she just released all of these tears and emotions just came up to the surface. 

Her scores went down from around 22 to a 15, which is a significant improvement. She told us afterward,"I'm feeling good. I had a good session in my doctor's office. She said my numbers haven't looked so good since I started counseling with her."

She also had chronic pain and this is one of the other reasons we were giving her the ketamine infusions. She said, "I don't need as much Percocet. I don't need as much Neurontin." And she felt like she was sleeping better.

We then have patient C who is a 49-year-old male history of depression and social anxiety. This patient has actually tried TMS or transcranial magnetic stimulation. And I think he did around 30 sessions with no real improvement. 

So he came to us, also treatment-resistant. His initial PHQ-9 was about a 17, and with him, it went down to a 7.

He said, "This is the first time in my adult life that I feel something is actually changing" and "I had a great weekend. I've also noticed a big improvement in my ability to talk to people. And I'm feeling more desire to connect with others. So feeling really excited and hopeful.” 

He was actually one of our earliest patients and came back for booster infusions about two years after his initiation series. 

He's made significant changes in his life such as selling an old property that was going to cause some stressors for him.

So to summarize what we covered in part one, the current state of depression and psychedelics. Depression is a major issue in America and in the world and it can lead to suicidality.

For psychedelics, this renaissance is occurring and there's a lot of research. The question is how do we take that clinical research and put it into practice? 

Now, you know some steps that you need to consider before beginning your own practice. 

Lastly, I'm discovering more and more that ketamine is just one part of the treatment. I believe one of the things that help our patients is kind of having this bio-psycho-social-spiritual framework together with the integration component and preparation. 

We have different models from other ketamine clinics out there, and there's this huge diversity of how it's done. But I believe that having this framework and a more holistic approach can be incredibly beneficial for our patients.

Question And Answer

ROB - YPSG

I just want to thank you so much Dr. Ko. I really appreciate you being here and giving that presentation. 

For Q and A, most people already know the rules, but just raise your hand, I'll call on you. I can unmute you, and then if you wouldn't mind, we'd really appreciate it if you turned on your camera so we can see your face and have a little bit more of a conversation, and then you can also put your questions in the chat and I'll read those as well. So we will start with Rob Palmer.

ROB PALMER

Dr. Ko, first of all, thank you so much for that talk. I have so many questions, but I guess one of the questions I was especially curious about is your route of administration. 

There's so many different approaches out there like intravenous or intramuscular or lozenges, or some combination of different approaches. 

You have an article on your website explaining why you chose that approach that you chose, at least at that time. I don't know if things have evolved since, but I'd love to hear you talk about your thinking both in terms of the therapeutic value of the approach, but also the sort of logistical and practical matters too that sometimes people overlook, just thinking strictly in theoretical matters and aren't taking into account on the ground perspective. So I'd love to hear you talk about that.

DR. KO

Thanks, Rob. Great question. And I really appreciate you bringing that up. So yes, there are different routes of administration. There's IV, there's intramuscular, there's intranasal, there's oral. My focus is really on IV, and the reason is it's a hundred percent bioavailable. 

So if I put in 50 milligrams of ketamine, I know a hundred percent of that is going to be administered. Whereas with the other routes, it's a bit less. For example, if someone is getting intramuscular, it's about 90% and then it can vary also. If they put the needle into the part that's more fatty, more muscle, then it's going to create different bioavailabilities. Then with an oral tract, I think it's around 20 to 30%, depending upon saliva content and these host of other factors.

But I really want to use the minimal effective dose because although ketamine is safe, it can cause issues, right? 

There have been reports of ketamine-induced, neurological tract dysfunction ketamine induced psychosis. It can cause liver inflammation. Some of these things were what was playing into my mind as I'm deciding which route. One of the things that I love about IV ketamine is that it's delivered intravenously via an infusion pump. This means it's slowly administered and a lot of studies are going for around 0.5 milligrams per kilogram which is what I typically start out with. 

I then increase the dose, and so with each session in general, I'm increasing the dose 0.6, 0.75 mix per kg, 1 mix per kg to get a really good effect for the patient.

The nice thing about IV is because it is slowly administered, I know the exact amount I can stop it at any time. So if a patient is having some sort of reaction or they want to stop it I always tell patients that they can get off the ride at any time. 

All I need to do is hit stop on the infusion button and then the effects of the ketamine will rapidly fade. 

In addition, when you have an IV, ketamine can frequently cause hypertension, it can cause nausea, it can cause anxiety. And because I already have IV access, I'm able to administer benzodiazepines if needed. I'm able to administer beta-blockers if needed, I'm able to administer anti-medics if needed. 

So it was having access to different medicines which makes it really important. 

And the other thing I didn't mention is one of the things that we do at our clinic is we are continuously monitoring our patient's vital signs.

So I'm looking at their cardiac rhythm. I'm looking at their pulse ox. I'm looking at their blood pressure, I'm looking at their respiratory rate. And one of the things that I've seen is hypoxia. 

And I know historically we believe ketamine in general is safe. It doesn't create respiratory depression, but I have actually seen a slowdown in patient's respirations where they're breathing four breaths per minute, and their oxygen level will drop. 

Fortunately, because we are monitoring them, I'm able to administer supplemental nasal cannula oxygen, and then their saturations will go right up. I think, regarding the other formulations, there are a lot of things that are happening now, especially with a low dose, even a home ketamine where there's different companies and startups doing at-home lozenges.

This is an area for research and there's not as much robustness of data though, because all of the studies that are being done, whether it's at Mount Sinai or Yale, is predominantly done intravenously. 

And then the last thing that I want to touch upon is, in addition to mood disorders at our clinic, we're treating patients frequently for things like pain disorders. So like complex regional pain syndrome, trigeminal neuralgia, fibromyalgia, and with those, you're going to need a higher dose for a longer duration. And again, with the higher dose of ketamine, that can lead to additional side effects that we want to watch out for.

ROB - YPSG

All right, next Robin Martin.

ROBIN MARTIN

Hi, I'm Robin, everybody. First, I want to really want to thank Robin and the Yale Psychedelic Group for having this, and Dr. Ko I really appreciate you joining. 

I really liked your expansion of the bio-psycho-social model into the bio-psycho-social-spiritual model. And I really appreciated your emphasis on preparation and integration and the experience itself. I think that that's really lacking in a lot of ketamine clinics I've seen. 

Rob kind of stole part of my question. So I just graduated residency and I'm planning on joining a private group practice of young mostly child psychiatrists. They do a lot of family therapy. They have a TMS clinic there. They have a lot of adults that they want to treat them. 

I'll be joining them as a general adult psychiatrist. And they're very open to me starting a ketamine clinic there. But basically, it's a psychiatry group and they don't have any experience in that. So I’d really appreciate your guidance because this is the exact kind of thing that I'm needing right now.

I want you to expand on the practical considerations of being; for example, I've only had my primary psychiatry training. I'm not an EM doctor, I didn't train in anesthesia. 

Do you think in order to get those kinds of malpractice, overage, and stuff like that, would I need to do additional training or be prepared to deal with certain medical complications that could arise?

DR. KO

Yeah. Great question Robin. And I'm very excited for you because this is a really good question. 

In general right now at the ketamine clinic space, there are probably three specialties who are doing ketamine infusions. And as you've mentioned, anesthesia, emergency medicine, and psychiatrists. 

And so right now what's happening is psychiatrists are administering ketamine and they are being covered for malpractice insurance. Now one of the things to note is that when you are using it for mood disorders, it's typically a lower dose, right? So you're doing 0.5 milligrams per kilogram in general when you start. Versus like when you're doing it in the OR or ER, where you’re pushing 1-2 mg per kg over a really short period, one minute, two minutes so it's like this really blast off. 

Now, with the ketamine infusions, it's a lower dose to start with and it's slowly infused over a 40 minute-ish infusion.

And so because of that, there are less concerns for significant side effects. I think what would be most important for psychiatry is to monitor their patients because like I mentioned, the O2 saturation can frequently drop and although you're a psychiatrist, you're still a doctor and you know the biology. 

You know you've done your intern year and you have that medical background. So I really believe that a psychiatrist can provide low-dose IV ketamine for mood disorders. 

Now, if we were to consider something like CRPS (complex regional pain syndrome) for those patients, I'm treating them for four-hour infusions with a really high dose. And so I'm thinking about my psychiatric colleagues and they're not really entering that pain category for patients. They're more entering the space of mental health, mood disorders, depression, PTSD, anxiety. And I think that is totally within the realm of capacity for psychiatry.

ROBIN

That's pretty reassuring, thank you.

DR. KO

Yeah. And the other thing I do want to mention, Robin, is there's a lot of evidence or not a lot, but there's more evidence coming out for teenagers with ketamine depression, especially with treatment-resistant. 

At our clinic, I have treated 17, 16 year old's at the youngest age. And I know other clinics that have even treated 12 to 13-year-olds. So that would be another possibility. 

Because we're in Palm Springs, California, which is kind of a retirement community, I've treated 78-old patients with IV ketamine.

With those two categories, I'm being really conscious of the dose, probably even lowering the dose in some cases, because they're more sensitive to the medication and being really cognizant of how it's affected their vital signs. And of course, working with their psychiatrist because my background is in emergency medicine. My expertise is not mood disorders. 

I really love a team-based approach where I'm collaborating with the psychiatry, with their therapists so that it can be teamwork. And again, ketamine is just one part of it, and kind of that integration and talk therapy, whether it's with their psychotherapist or a coach or whatever it may be, is really important as well.

ROBIN MARTIN

Yeah. I'm curious about those collaborations and just to follow up on it with a question, if I may. Looking at the economic model, some of the people are starting to use Spravato. I've heard some of the local providers say that it's hard to make money doing that because their requirement for the REMs is particularly kind of burdensome. 

So some people are doing these sort of group sessions to try to lower the costs, you know. As psychiatry, I could probably bill for the therapy component and the evaluations, but we'd probably still be charging cash for many of these treatments. But I'm wondering if you have any thoughts or tips around that, maybe how to approach those issues.

DR. KO

Yeah. Great question as well. So for those of you who don't know, there's Spravato aka S-ketamine (esketamine). So ketamine has the two enantiomers containing R-ketamine and esketamine.

Johnson and Johnson, took out half of the esketamine and created this nasal spray. And I think each nasal spray is about $800 or $900 per spray of esketamine. So the cost is very high and I would say probably even higher than just paying out of pocket for an IV ketamine infusion. 

I think the average cost for an IV ketamine infusion is about $500-ish but then compared to like one dose of receiving treatment of intra-nasal Spravato, it's really high. Now that is covered by insurance and the patient and the doctor have to go through various hoops to make that happen.

Like patients who have tried multiple antidepressants, they need to be on an antidepressant. And one of the things about esketamine is there was a meta-analysis systematic review that just came out, I believe this year or last year. And they compared intranasal esketamine Spravato with IV racemic. 

What they found was that the IV racemic ketamine was far superior than the intranasal esketamine. 

There was another interesting rodent study where they gave either S-ketamine or R-ketamine, and they found that it was actually R-ketamine that provided more of the antidepressant effects and for a longer period of time. 

So with Johnson and Johnson, they're a big company. Their goal is to maximize profits for their shareholders. So I totally get it but I think this is one of the reasons why we need to have this generic IV racemic ketamine available, just because the evidence shows that it's much more effective.

And the other point is regarding health insurance coverage, and I believe Massachusetts Blue Cross Blue Shield just recently started covering IV racemic ketamine. 

From a health insurance perspective, they're thinking “do I want to pay 800, 900 bucks for Spravato or pay less and get a more effective response?” 

So this is slowly transitioning where insurance companies are being an aid to cover IV racemic ketamine. And again, because you have that psychiatric background, I know of other clinics where they are billing the insurance company because they're in that work and they're billing for the psychiatric component. But then the patient is paying out of pocket for the infusion. So the patient is still paying some, but not as much because a portion of it is being covered under the psychiatric building codes.

ROB - YPSG

I had a quick question. I was wondering if you could talk a little bit more about how you do the integration or how you do the preparation, and then how this sort of bio-psycho-social-spiritual approach gets woven into all of this. A little, maybe more of the specifics. I think people will be interested to know a little bit more about that.

DR. KO

As you know, psychedelics set and setting is really important. And so I have a list of guidelines, like 12 different things that I tell the patients to do. Just send them a PDF and say, Hey, these are things I want you to focus on. 

And that looks like doing things that are going to help them, specifically journaling, exercise, eating healthier, avoiding social media, and avoiding the news. So they're following those guidelines as best possible. No one's going to be able to follow it perfectly, but I say, "Do this as much as you can, and throughout the series of infusions, continue doing these practices." 

For example, we had one patient whom we recommended no alcohol for five days before the treatment and throughout this series of treatments actually.

And it was really great because he did that preparation. Then by the sixth infusion, I noticed that his blood pressure was normal. When he first came in, it was always slightly elevated. And I said, "Hey, what's been going on?" And he's like, "Oh yeah, I haven't drank for three weeks, and I'm feeling really good.” 

So that's part of that preparation. 

And for integration, this is probably one of the most underrated aspects of ketamine therapy. They've had a transcendental ego dissolving, possibly even a near-death experience and it's really out there. So how do I bring that into practice? 

One example would be someone stopping drinking. Or I had another patient who started going to church. I didn't tell him to start going to church. He already had that background and decided on his own. 

So I think about integration, and someone once said integration is like doing homework, doing what you need to do. And because we all kind of know what we need to do and having the patient do it is really helpful. 

Ketamine seems to be like a catalyst because ketamine works blockade of glutamate activity on that NMDA receptor and ultimately downstream that leads to increased brain-derived neurotrophic factor. We know that that increases neuroplasticity. 

What's great about the ketamine therapy is that they kind of get unstuck. They're incorporating these new habits and these new beliefs, and that's going to help with the integration because they have that neuroplasticity from the ketamine therapy.

ROB - YPSG

Okay. So it sounds like it's kind of a guidance you're giving to them. Things to do befor and things to do after. Is there any sort of integration with therapy afterward with the psychologists to people like that to meet with and just sort of process what might've happened?

DR. KO

Yeah. So I know some clinics are doing ketamine assisted psychotherapy. We don't really focus on that because we want the person to have the experience rather than be externally focused, looking out, being out. We really want them to go in. 

And what they'll do though that coaching or therapy session is really important because, for example, they can just journal their experience, write everything down, or they're going to remember it too. They'll schedule an appointment with their therapist for the next day and then they're going to say, "Hey, I remembered I had this memory of my dad” or “I had this memory of this traumatic thing that came up and I totally forgot about it, but the ketamine just seemed to bring it up to the surface.” 

And we really recommend that they schedule an appointment with their therapist and so that they are able to decompress and process.

I think what's really profound is meaning-making. Humans are meaning-making machines and it's like, “Alright, I had this intense experience. What's the meaning I can make from it?” And with a therapist, if we are able to facilitate that meaning-making process, I think that can be a really important part of that integration.

ROB - YPSG

Okay, great. Thanks a lot. All right. I will toss it over to Muhammed.

MUHAMMED

Hello. Can you guys hear me? Alright cool. So thank you so much for the incredibly informative and practical information. I really appreciate it. 

My question, I guess, looks a bit ahead, a decent amount of years. So once other psychedelics, like psilocybin, MDMA ibogaine, LSD kind of gain traction and become approved for clinical use, how realistic do you see this kind of general psychedelic clinic being established? 

Do you think you would have to have an establishment for specifically ketamine or specifically psilocybin, or do you think it's possible for there to be this general psychedelic clinic where people of different ailments can come in, and then there's a psychedelic or a psychedelic ward or an MDMA ward or something like that?

DR. KO

Yeah, that's a great question. And as you know, those are currently undergoing FDA trials. But with evidence, I think there was a new journal or medicine article looking at psilocybin versus SSRIs, and they found it was really effective as well as the MDMA studies with MAPS. 

So, in the future, will there be a psychedelic clinic incorporating all of those different aspects? I mean, Mohammed, the fact that you were thinking about it, it might be you that's creating it. And this space is crazy in that we're literally on the cutting edge right now. 

What we need are leaders and pioneers who have these visions of, "Hey, this is what I want to create. This is the way I want the psychedelic renaissance to occur." I love how you're looking forward to the future. 

We get to create this. I'm young, you're young, we're all kind of these young and up and newcomers so we get to create the world that we want it to be in. And that might look like a psychedelic center, a clinical center where you have a group of psychologists, psychedelic therapists with all these different modalities and saying, "Studies have shown that for this type of depression, this subtype of depression, psilocybin is more effective or this subtype or this PTSD may be more MDMA.” So, yeah, I think that is very possible. 

The one challenge that I see right now though, is looking at Spravato. With Spravato, they have REMS, so that's like a risk mitigation component. And so there's a lot of restrictions with it. They have to watch the patient for two hours at a REM-certified center. They're all of these regulations around Spravato. 

What I also see happening with MDMA and psilocybin is once those become FDA approved, which I think they will be in the next two to three years, five years maybe, there's going to be restrictions. 

For example, with MAPS and the MDMA they actually have, I think it's like a protocol, the MAPS protocol, where you have to do 12 therapy sessions. It's only, I believe, 2 MDMA sessions. 

There has to be a male therapist, a female therapist, and that's going to have to be incorporated to allow them to get insurance coverage. And so I would say the regulations behind how it's being administered is going to be one of the challenges for sure.

I just want to touch upon this because we are in such a cutting-edge space, even with Spravato. But a lot of insurance companies don't know how to bill for it. Things like billing for nasal esketamine because there are these other components. And there is no CPT code for it. 

The medicine is coming, but how is the health insurance company going to respond? What CPT codes are going to need to be created? How is the AMA going to play a role in this?

MUHAMMED

So, with those challenges that you've stated, do you think that your MBA or getting an MBA is helpful and navigating that? Because I'm quite early in this whole path and just now applying for medical schools, and I'm wondering what is the path for the accreditations I should acquire before getting my skin in the game? What should I have on my name before I jump into this?

DR. KO

I mean, definitely start with the MD because you're going to need that. For me, when I started med school, there was no discussion of psychedelic clinics. There was no discussion of ketamine for off-label use. 

I was just personally interested in the business side and entrepreneurship. So I pursued a combined MD, MBA program, which was great because it was only five years. It was just nice because it was combined and I believe it did give me a bit of confidence to understand finance, strategy, organization, leadership, and accounting. 

And I knew that there was a deficit in medical education right now. Like I'd mentioned, all we're taught is biology and pathophys, but medicine is a big business and I really believe that doctors need a business background.

If we're not leading the medical business, then it's going to be some MBA who doesn't know medicine leading it. And there was a study that showed that hospitals that have CEOs who are MDs actually do better than hospitals that have CEOs without a medical degree. 

So, if there's even an interest in getting an MBA background, for me, it was really helpful and useful. So I would highly suggest and recommend it, but it's not necessary. 

MUHAMMED

Thank you so much.

YSPG

All right. I see Daria. Yeah. 

DARIA

Hello? Can you hear me? Sorry about that. Yeah. Thank you so much. I wanted to echo everyone's gratitude. Dr. Ko.

I just wanted to ask if you would give us more insights and any anecdotes or thoughts about the strict contraindication of using ketamine in anyone with a history of any kind of psychotic episodes or psychosis. 

I mean, as we all know, medical and psychiatric histories can be quite ambiguous and hard to pin down sometimes, particularly in that realm because we have depression with psychotic features and so forth. And people sometimes have, to your point about the bio-psycho-social aspect, people struggle sometimes to articulate the quality of their experiences and sort of reality and imagination and so forth. 

And so have you had difficult situations where you had a patient who was desperate to try ketamine or where something went wrong because someone had a history of psychosis or just your general thoughts on that?

DR. KO

Yeah. Great question, Daria. I just finished listening to a podcast by Tim Ferriss. I think he was interviewing Dennis McKenna and one of my take-home points from that and just reiterated again, was the four S's. 

So we always talk about set and setting but the other two are screening, set and setting, and then support. Talking about screening, it's really important because ketamine can be very effective. It can be transformational, but it's not for everyone. And with a lot of these studies that have been done, they always screened outpatients who had a history of psychosis or a family history of psychosis. 

At our clinic, I screen really rigorously. We had a patient who was not doing too well, and when I did the consultation call, she told me, "Hey, you know, my brother has schizophrenia. My dad has schizophrenia. I don't personally have schizophrenia." And I told her there is a risk. 

And since studies haven't been done because they always excluded those patients who had that family history or a personal history I told her there's a risk and she might do great now but it could deteriorate where it does trigger into a psychotic episode. 

Personally, we haven't had any issues, again because of that rigorous screening. 

By the way, I forgot to mention that they had manic episodes. So there have been case reports and studies where someone will get ketamine infusions, and it will literally trigger mania. And because that's one of the things that it can cause, there's definitely a risk there. 

This is why screening is really appropriate or very important. Collaboration with the psychiatrist is really important and letting the patient be fully informed of the risks, the benefits, the alternatives so that they can make a fully informed decision.

ROB - YPSG

All right. Damien Tau.

DAMIEN TAU

Hey there, what a great and exciting presentation. And I'm very inspired by your work and what you've been up to Dr. Ko. I wanted to ask you if you care to answer, have you used ketamine for yourself?

DR. KO

That is probably one of the most frequently asked questions that I get from my patients, and I personally have not. And I know with different psychedelic substances, there are two schools of thoughts on this where it's like, "Hey, I'm doing MDMA therapy, I should personally have MDMA experience so that I can relate.” For example, the shamans of Peru will drink Ayahuasca as they're giving it because they want to be a part of the experience. So, I think that's about history. 

Each medicine has its own history, right? So with Ayahuasca, that's the history, with MDMA that's the history, but with ketamine, the way it started was not that way. So when it was first discovered in 1964, by Dr. Stevens, Wayne State University, he wasn't administering ketamine to himself.

He was administering it. Actually he invented it, but his colleagues weren't administering it to themselves first. They were administering it to healthy subjects. 

Ketamine has a history of being administered to other people, to the patients. So I haven't personally partaken in it. 

The other school of thought is like, “Well if there's an oncologist and they don't have breast cancer, do they need to do chemotherapy so that they can best know what chemotherapy feels like so that the patients that they're giving chemotherapy they can relate?” 

And I would argue if they don't have breast cancer, they may not need to be on chemotherapy. So similarly, if I had PTSD or I had treatment-resistant depression, and I had tried Bupropion and Prozac and Lexapro, yeah I would definitely go for it.

and I've recommended it to friends and family. They may not come to my clinic as they live in Seattle or in different places so I would recommend ketamine clinics in their area.

So, a different background and a different culture by ketamine therapy has arisen.

DAMIEN TAU

Yeah, I'm excited to be a part of the psychedelic group that's opening up a center here with a lot of focus on the integration part. And my question was kind of coming from the place of like, we are in the business to help people with many, many different ailments and are deeply suffering, but I'm also very curious of the relationship to just exploring your consciousness through medicine and through whether it's ketamine or plant medicines or psychedelics in general for healthy adults.

DR. KO

Yeah. I would say that's definitely the cutting edge for sure. 

Ketamine is currently being used off-label. We're using it, off-label for depression. And now when I think about something, I call it “super off-label” where it's like, “ I want to create a new song because I'm a musician and I'm doing great. I just need to get my creative juices flowing.” 

And because ketamine, it's a controlled substance -- DEA Schedule II -- it's strictly monitored. So each time we use ketamine, we're logging it, and because it's strictly monitored, I really want to use it with integrity. 

I feel like ketamine clinics were kind of already on the cutting edge of therapy because it's off-label. It's not super common. People are becoming more aware of it. So to use it for these other purposes of psycho-spiritual growth or creativity, or other things that may not be indicated, would be pushing the border even more, which might increase regulation from the DBA in the future. 

DAMIEN TAU

Yeah, I did want to ask about it, most of my experience is just with intramuscular. So I'm very curious about the IV drip. Do many people in your experience ask to come out?

DR. KO

I would say less than 1%.

DAMIEN TAU

And the very few that do what's that like for them? That sounds like an interesting place to be?

DR. KO

It's pretty scary. So 20 minutes in and they hit this tipping point and then they'll start having a panic attack and they're breathing fast, and they're like, "Where am I? What's going on?" And especially people who are not familiar with that kind of state, with that psychedelic state, it can be scary, especially because it's the mind and the body it's associating with and their ego. 

It can be pretty traumatic. I feel preparing the patient beforehand can be really useful. And I tell them, "It might get scary. You may feel like you're at a certain dose, you may feel like you're going to die." And I tell them, "If you experienced that, go towards it. It may feel that way, but trust me, I'm watching all of your vital signs. I'm looking at your blood pressure, I'm doing continuous cardiac rhythm. I'm going to let you know if there is something concerning, but I want you to just trust and go with it.”

And because I developed that therapeutic relationship beforehand they trust me. And paired with that medical setting, I feel patients are more willing to let go and surrender into that. 

DAMIEN TAU

Yeah. Awesome. I appreciate your response and being here. 

DR. KO

Yeah, you're welcome. 

ROB - YPSG

Alright. Fabiana.

FABIANA

Hi, I thank you for facilitating the session. I have a question around, I'm curious if you partake in any advocacy or coalition work to help move the needle for state-based regulations on the legislative landscape, and really curious to find out what has been productive to help maybe eliminate some of the red tapes when considering the future of making this less illicit?

DR. KO

Are you referring to ketamine or for other psychedelics?

FABIANA

I think about other psychedelics and in general.

DR. KO

So we're in California and I know there have been several bills at least from a local level to Oakland. California for example decriminalized all psychedelics, I believe, and also in Oregon and I believe Colorado. 

There's a concern though. As physicians, we're bound by certain rules and regulations, right? To get a medical license takes a lot of work. And I would say that there is a challenge of promoting things that may not be approved quite yet. 

I think about, let's say like Portland, Oregon, where psilocybin is legal or decriminalized, right? So there are probably a lot of clinicians jumping on board and thinking about giving psilocybin. And because they have their medical license on the line and depending upon which mushroom you may get which have different concentrations, it's really hard to get an accurate dose. There are some challenges with that. 

I think overall though, just the evidence is going to be key like with Johns Hopkins Center for Consciousness and Psychedelics as more data becomes available. That's going to be crucial, but I don't think data's the full story or the full thing that's gonna move the needle. 

I think what's really going to move the needle and what's always moving the needle are stories. So patients telling their stories, or you telling your story like and how it’s helped you. 

Because that's what really moves the needle because I think data is supportive, but people aren't moved by data. People are moved by emotions and justify it with data. And the way we transform emotions is through storytelling because we’ve been storytelling creatures for a hundred thousand years. We've sat around campfires telling stories and that's what motivates and inspires people, not P values less than 0.5. 

FABIANA

Okay. Thank you.

ROB - YPSG

All right. Rob.

ROB

Double dip on those Q and A's. Thank you very much again. Love the Q and A, so thanks for the questions, and thanks so much for the answers, Dr. Ko. You kind of teed up my next question here perfectly. 

I'm just curious, what are the big surprises you've had, positive or negative, pleasant or unpleasant, over this whole experience? Whether it's patient outcomes or whatever other things that have a surprise to you, some stories that you might have to share.

DR. KO

Yeah, that's a great question. One of the themes that I've been getting more and more is ketamine and these other substances are just one part of the therapy. And I really believe that it's the clinician who is administering it that plays a key role. 

And for the clinician who's administering it, they really need to know why they're doing it. They really need to know their intention. And I also think there's this part, this might sound cheesy, but this part is just unconditionally accepting and loving the patient as they are. 

You may not have to state it drastically, but just this feeling that the patient is receiving because I feel like a lot of people don't get that in their lives and just to have someone there sitting with them, paying attention to them can be incredibly therapeutic.

There was a study where they looked at all these different types of psychotherapy, like CBT and Adler and just all these different modalities. They were trying to compare which of these are the most useful, and what they found in that study is an odd one.

They found that the majority of the therapeutic benefit came from the relationship between the provider and the patient. And so how this ties around to ketamine therapy is yes, ketamine is amazing and super helpful. But it's the doctor that's actually making an impact. 

So just being really conscious of that and being aware of your energy and who you are as a being. That seems to be playing an integral role in the ketamine therapy. And that's some of the feedback that I get from my patients. They'll come from other clinics and they'll have the experience here, and they're like, "Wow, that was just completely different."

I think there's a component of that relationship, of this unconditional regard and acceptance and love for the individuals. 

ROB

That was an awesome answer. Very much what I was hoping to hear without even knowing it. So you put words to something I've definitely been thinking about, and I love that that's what you've been experiencing and coming to realize yeah. Awesome stuff.

DR. KO

Yeah. And for all the medical people out there, even if you're not doing ketamine therapy, even if you're just having a daily interaction with the patient, still bring that energy into the space. They may be coming in for chest pain, they may be coming in for abdominal pain, they may be coming in for whatever issue, we can still hold that space for the patient.

Just this unconditional loving, regarding, accepting space and for whatever issue, it just seems to add a little bit something extra. And as I was speaking, I did want to comment on the previous question about the advocacy component and I forgot to mention that this is a religious act. 

And I know that this is one of the workarounds where psychedelics like Ayahuasca for example, are actually becoming legal. So classic would be Santo Daime Church or the UDV church in America, where they're coming from the background of religious freedom, bringing it into the United States and saying, "Hey, this is part of our religious practice", and that's being allowed. 

In addition to the native American church with peyote, because it's part of their tradition and culture, they're able to access it legally. And it's federally approved in that situation for those religious freedom components.

ROB - YPSG

I'm curious to know what was the hardest part of starting this clinic? I can imagine it wasn't a very easy journey getting this thing up and running. 

DR. KO

That's a really good question. When I met Rob five years ago in 2016, the clinic didn't even exist and it took two years for me to actually do it. And I just made up excuses like I need to read more, or I need to have everything prepared before I actually do it. 

So I would say taking that first step of doing it and committing to it, because there's a huge activation energy in starting something up. And I would say once I took that first step of really committing myself and saying, "This is going to happen", that turning point was putting skin in the game when I signed that lease and I'm like, “Crap, this is real. Here's $50,000. Build this out.” And that made it real. 

It takes a lot of courage. And I would say the reframe that I had about that is life is an adventure. 

Imagine if you go to this imaginary Las Vegas and you play and start winning every single game. You're going to play blackjack-boom, every time you're going to play slots-boom billion dollars. And at a certain point, it's going to get boring if every single thing we know is going to work out. 

So if we can embrace this idea of the unknown and the possibility of it failing, then that's actually the adventure. Knowing that it may not work and embracing that, embracing the risk and saying, "I might just lose a bunch of money and still do it anyway." And for me, that's actually part of the enjoyment and spice of life.

ROB - YPSG

I love that view. Mohammed, I see you have another question. Well, actually I might pick on Savannah since she hasn't had gotten asked one yet, we'll come to you next Mohammed.

SAVANNAH

I'm not sure if anyone already asked this and it kind of goes into what you're saying, but I was wondering if you had any backlash from the medical community or your colleagues for starting.

DR. KO

That's a really good question, and yes, 100%. When I first started thinking about it, I started getting made fun of. Because my last name is Ko, they would start calling me “ Ko Ketamine” “Dr. Ko Ketamine”, are you going to get more ketamine? And so there was a little bit of good-natured ribbing, I guess. 

That was the minor stuff that I didn't really mind. But once I started getting myself out there, I have a post on White Coat Investor, which is this kind of a large blog for physicians. And I put a post on there describing my experience and I was reading some of these comments and they were hate comments, like, "You're just like another cannabis provider” and just all these hateful comments. There's definitely a backlash. 

The reframe about that which has been helping me is knowing that anytime someone is doing something different, we're going to face backlash. 

The best example of this that I can give is back in the 1800s, there was a physician named Dr. Semmelweis back in Vienna General Hospital. And there was something called a childbed fever, puerperal fever. One of the reasons that was occurring was the physicians and med students there weren't washing their hands between gross anatomy lab and delivering babies. 

So Dr. Semmelweis said, "Here's my idea. Let’s wash our hands." And when he started doing that at Vienna General Hospital, the maternal mortality rate dropped, and he's trying to tell his other colleagues to wash their hands as well.

For 40 years, they all ignored him and they called him a freak. They're like, "No, that's your bogus. That's not the reason why puerperal fever is happening XYZ." 

Now, of course, we know, yes, you want to wash your hands between the anatomy lab and delivering babies. It's obvious. But initially, when it first came out, there was a lot of resistance. 

And in the medical community, medicine is slow to change. I remember learning in school, medicine changes one funeral at a time. People get stuck in their beliefs. People get stuck in their default mode network and their training. 

What I've personally experienced is there has been backlash, especially with people who may be further out of training. They may not be more aware of the evidence. 

And I have noticed that the younger physicians, the more people who are up to date, they are open to it because they have seen the articles, and they're looking at the data, and they're open to it. 

You just need to be cognizant that this is going to happen. If you're going to start up a ketamine clinic, you're going to face backlash. And that's part of doing something different. That's part of standing out and being willing to also embrace that challenge as well because, at the end of the day, I'm not catering or serving those physicians, those psychiatrists, that's not my patient population. 

I look at my patients and I see the changes they've made and they tell me, "Dr. Ko, thank you so much. You've made a huge impact in my life." 

And I get Christmas cards now. When I was in the emergency department, I never got Christmas cards or cookies, and now I'm getting those baked and I'm like, "Wow, it's kind of nice. I'm getting homemade cookies." And I know I'm making an impact. 

It's not for everyone, but for the people that can make a difference, those are the people that I want to focus on while acknowledging and accepting the backlash that's naturally going to occur anytime I do something differently.

ROB - YPSG

I can't believe you weren't getting cookies in the emergency department. I'm going to go to Mohammed.

MUHAMMED

First off, thank you, Rob, for giving me the courage to double-dip. 

So there’s risk in starting your own practice, you saying I gave $50K and signed the lease and that's terrifying and whatnot. There always has to be a financial security component before jumping into this. 

Once you finished your residency, did you start out working for those large healthcare companies that you talked about, or did you kind of just jump into starting your own practice? Because one of my main fears is working for large healthcare companies and then feeling like I can't leave kind of feeling stuck in it.

DR. KO

Yeah, so I finished my residency in 2011 and I didn’t open the clinic until 2018. 

So during those seven years, I did work for a large healthcare company. As a matter of fact, right before, or a few years before I opened up the clinic, I was an associate medical director of an ER, and they were like, "We want you to be the medical director,” and that would have come with a lot more money and job security. But I realized that wasn't for me. 

So there's this saying, “whenever you're climbing a ladder, make sure that it's up against the right wall,” and when I saw the ladder that I was climbing and I saw the people ahead of me who were the regional medical director of this and the vice-chair of that, that just didn't resonate with me and who I am. 

And our lives are so short and brief on this planet. I'm going to live 80 years. I'm going to live 90 years if I'm lucky, right? I think of this concept of death and this preciousness of our life, and we have like literally a blip in life. 

Earth has been around for like 4.5 billion years, and humans have only been around for the past, whatever 200 millionaires or however many years, and my life is only just 80 years in the grand scheme of things and knowing this preciousness of life and what I want to do, what I'm passionate about. 

That's what really motivated me. Life is short. I want to do what I'm going to do. 

And then for financial security because it's real, I mean, student loans are real, I think the average med student graduates with 250K of student loans so we're almost like indentured servants. So yeah, for those first seven years, like I've worked my butt off, paid off my student loans. And even when I was starting up the clinic, it wasn't like I was done with ER. I continued working for these healthcare corporations part-time though. 

So, when I started, I was doing 2-3 shifts in the ER per week, and then I was doing 1-2 days at the clinic. Because when I first started the clinic, it's slow, and not a lot of patients, and as time progressed and the patient base builds, then I was tapering the number of clinical shifts up until 2020 with the COVID-19 pandemic, with our baby being born, I decided to step out of the ER completely for now. 

I mean, things may change and just focus 100% on ketamine, but yeah, you definitely have to consider your finances. Sometimes you may work for a large healthcare corporation but you don't have to necessarily do that full time.

The other component, which is more of a practical thing, is just to keep your living expenses low. I kept my living expenses low. When I graduated residency, I knew some people who bought the latest Tesla or a new house. And for me, I didn't do that. I continued driving my Honda Accord, and bought a small place. 

I kept my expenses low and because I kept my living expenses really low and living frugally, then I had space, I had time, I had extra money so that I wasn't making monthly Tesla payments. 

So I think the key is to do it wisely financially, where you're able to taper down clinical shifts. You may be working for a large healthcare corporation, but then you can also gradually increase the private practice or the ketamine on the side inside or in the future MDMA or psilocybin or whatever may come out. 

MUHAMMED

So insightful. Thank you so much.

ROB YPSG

All right. Anyone else has any questions? I think we're basically running up on the end of time right now. Maybe this is probably a good place to wrap things up. I will unmute everyone and let everyone say their thank yous to Dr. Ko.Dr. Ko, do you have any parting words, any last things you'd like to say?

DR. KO

I'm just so grateful to be able to present and share my experience with you. This is William, Rob, Yale Psychedelic Science Group, just super grateful, and you guys you all are being courageous in even starting up an organization like this so I wanted to just acknowledge you and give you a shout-out thank you so much for the work you're doing. We are the change and we can be the change and I think this is living proof of it so thank you so much. 

ROB YPSG

All right. Thanks a lot. I'll unmute everybody. If you feel so inclined, you can shout out a thank you. 

EVERYONE

Thank you. Thanks so much, Dr. Ko and thank you.

ROB YPSG

Bye, everybody. Have a good night.

We hope you enjoyed learning abour our journey in starting our ketamine clinic! If you’re ready to start your own journey, join our email list and be notified about the next free webinar and open registration for Ketamine StartUp.

In this blog, adapted from a talk given to the Yale Psychedelic Science Group, you’ll learn about the current state of depression & psychedelics, the 7 key steps in opening a ketamine clinic, and finally our approach to providing ketamine infusions at our clinic and case studies. Check out the blog to learn more!

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